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PUBLICATIONS BY THE AUTHOR 

" Variations of Ribs in the Primates," Journal of Anatomy and Physi- 
ology, vol. xxxi. 

" Three Dissimilar Cases of Multiple Lesions of the Central Nervous 
System," Mott's Archives of Neurology, vol. i., 1899. 

" Hemiatrophy of the Brain, and its Results on the Cerebellum, Medulla, 
and Spinal Cord " (in conjunction with F. W. Mott, M.D., F.R.S.), Brain, 
part xc, 1900. 

" Primarv Degeneration of the Motor Tract " (in conjunction with 
F. W. Mott^ M.D., F.R.S.), Brain, part c, 1902. 

" Hypertrophy of the Brain," Quain's Dictionary of Medicine, 1902. 

" The Subsequent History of Children born during Insanity of the 
Mother," Lancet, May 17, 1902. 

"Amentia: Its Causes, Classification, and Pathology," Mott's Archives 
of Neurology, vol. ii., 1903. 

" Insanity in Imbeciles," Journal of Mental Science, January, 1903. 

" Amentia," Practitioner, September, 1903. 

" Disseminated Sclerosis," Review of Neurology and Psychiatry, July, 
1904. 

" On the Relations of Epilepsy to Amentia," British Journal of Children's 
Diseases, July, 1904. 

" The Problem of the Feeble-Minded, with Especial Reference to the 
Legal Powers for their Training and Detention " (address at the Guildhall 
Conference, October 14, 1904), Charity Organization Review, November, 
1904. 

" Special Training Considered from the Physiological Standpoint " 
(address to teachers of the National Special Schools Union, July 1, 1905), 
British Journal of Children's Diseases, October, 1905. 

" The Varieties of the Feeble-Mind " : address at the Conference of 
After-Care Committees, Nottingham, October 12, 1905. 

" Report on the Number and Condition of the Mentally Deficient (in- 
cluding Epileptics) in Somersetshire " : presented to the Royal Commission 
on the Feeble-Minded, December 31, 1905. 



MENTAL DEFICIENCY 

(AMENTIA) 



Plate I. 



TYPES OF BRAIN CELLS OCCURRING IN AMENTIA. 
(Drawn as seen under T V inch oil-immersion lens.) 



Fig. i. 



3 S 

• 



Fig. 



mm 





Fig. 4. 



A 




A 



Fig. 5. 



Fig. 6. 




Fig. 3. 




4 



1 rf\ 






Fig. S. 



A. F. TREDGOLD, del. 1908. 



Frontispiece.} 



DESCRIPTION OF PLATE I. 

Fig. i. — Incompletely developed nerve cells (neuroblasts), from layer 
of small pyramids of frontal cortex. 

Fig. 2. — Incompletely developed nerve cell, from middle pyramidal layer 
of motor cortex. 

Fig. 3. — Neuroglia cell ; from a case of sclerotic amentia. 

Fig. 4 — Incompletely developed nerve cells, from layer of middle pyra- 
mids of frontal cortex. 

Fig. 5. — Atrophied and distorted medium pyramidal nerve cell ; from 
a case of sJerotic amentia. 

Fig. 6. — Medium pyramidal cell from frontal cortex, undergoing subacute 
degeneration ; from a case of secondary amentia. 

Fig. 7. — Medium pyramidal cell from frontal cortex, undergoing chronic 
pigmentary atrophy. 

Fig. S. — Pigmented cell of hippocampus; from a case of amentia with 
epilepsy. 



MENTAL DEFICIENCY 

(AMENTIA) 



K 






BY 

A. F. TREDGOLD 



L.R.C.P. Lond., M.R.C.S. Eng. 

Consulting Physician to the National Association fok the Feeble-Minded, and 

to the Littleton Home for Defective Children; Medical Expert to the 

Roval Commission on the Feeble-Minded; Formerly Research Scholar in 

Insanity and Neuropathology of the London County Council and 

Assistant in the Claybuky Pathological Laboratory; Late Resident 

Clinical Assistant in the Northumberland County Asylum, etc. 



NEW YORK 

WILLIAM WOOD & COMPANY 

MDCCCCXII 



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TO 

ALL THOSE PERSONS OF SOUND MIND 

WHO ARE INTERESTED IN THE WELFARE 
OF THEIR LESS FORTUNATE FELLOW-CREATURES 



PREFACE 



During the past few years the subject of mental deficiency has 
evoked a large amount of attention from many prominent 
persons interested in social and philanthropic questions. To 
members of the medical profession in particular it is one of much 
importance, on account of their responsible duties connected 
with its diagnosis, with the treatment and training of these 
patients, and their examination and certification as to fitness 
for special classes and schools, training-homes, and asylums. 
And there is no doubt that with new legislation, which cannot 
now long be delayed, these duties and responsibilities will be 
considerably increased. 

For these reasons I venture to hope that the account which I 
have attempted to give in these pages regarding the incidence, 
causation, pathology, mental and physical characteristics, social 
relationship, diagnosis, prognosis, and treatment of persons 
suffering from mental deficiency, will be found to justify its 
publication. 

To a great extent this account is based upon observations and 
researches which I have been making for close on ten years, but 
I have also made full use of, and frequent reference to, the 
writings of many other workers in this field. Valuable help, 
permission to examine cases and make use of notes and illustra- 
tions, has been generously accorded me from many quarters. 
In particular I would like to take this opportunity of gratefully 
acknowledging my indebtedness to the members of the Asylums 
Committee of the London County Council ; also to Dr. Francis 
Warner, London ; Dr. G. A. Sutherland, London ; Dr. John 
Thomson, Edinburgh ; Dr. F. W. Mott, F.R.S., Pathologist to 



viii Preface 

the London County Asylums and Director of the Pathological 
Laboratory ; Dr. R. R. Alexander and Dr. P. BaiJy, Hanwell 
Asylum ; Dr. W. J. Seward, Colney Hatch Asylum ; Dr. J. M. 
Moody, Cane Hill Asylum ; Dr. Robert Jones, Clay bury Asylum ; 
Dr. T. W. McDowall, Morpeth Asylum ; Dr. F. R. P. Taylor and 
Dr. C. A. Marsh, formerly of Darenth Asylum ; Dr. C. Caldecott, 
Earlswood Training Institution ; and Dr. R. Langdon Down, 
Normansfield Training Institution. 

The greater portion of the microscopical work was carried out 
in the Claybury Pathological Laboratory, during my two years' 
tenure of the London County Council Research Scholarship in 
Insanity and Neuropathology ; and to the unequalled advan- 
tages which this scholarship afforded for clinical and patho- 
logical research in these fields of medicine I desire to pay a 
grateful tribute. 

Finally, I wish to express my indebtedness to the recently 
issued voluminous Reports of the Royal Commission on the Care 
and Control of the Feeble-Minded. Of the mass of information 
contained in these, regarding the number and condition of the 
mentally deficient population of this country, I have made full 
use. It is necessary, however, to add a word of explanation 
with regard to statistics. Under the term " mentally defective " 
the Commissioners include sane epileptics. Since, in my opinion, 
these should not rightly be classed as aments, I have considered 
it advisable to make independent calculations from the original 
returns — hence the slight discrepancy between the two sets of 
figures. 

A. F. TREDGOLD. 

6, Dapdune Crescent, 

Guildford, Surrey, 

September, 1908. 



TABLE OF CONTENTS 



PAGES 

PREFACE ------- vii, viii 



I. INTRODUCTION ------ 1-3 

Mental deficiency. Dementia. Amentia. Variations in 
" normal " mental capacity. Definition of the " normal " 
mind. Definition of amentia. Relation of amentia to 
normal, to dementia and to insanity. 



(S> 



II. INCIDENCE - - - - - - - 4-13 

^"*^ Difficulty of enumeration. Investigations of the English Royal 
Commission of 1904. The number of aments in England and 
Wales. Incidence of the three degrees of amentia. Incidence 
of amentia relative to insanity. Location of aments in 
England and Wales. Incidence with regard to sex. 



J£) 



III.) CAUSATION ------ i 4 _ 5 o 

^<y A. — Intrinsic Factors (Heredity) : 

Diseases of the nervous system. Alcoholism. Tuberculosis. 
Syphilis. Consanguinity. Age of parents. 

B. — Extrinsic Factors (Environment) : 

Acting before Birth. — Abnormal conditions of mother during 
gestation. Mental. Physical. Illegitimacy. Maternal 
impressions. 

Acting during Birth. — Abnormalities of labour. Primogeni- 
ture. Premature birth. 

Acting after Birth. — Traumatic. Toxic. Epileptic and infan- 
tile convulsions. Malnutrition. 

General Considerations : 

Modus operandi of intrinsic and extrinsic factors. Illustrative 
family history charts. Factors of causation in regard to 
local variations of incidence. 



Table of Contents 




K • VAGES 

IV.; PATHOLOGY - - - - - ■ '51-70 

The development of the normal brain. 

Pathology of Amentia : 

The essential basis of amentia. 

Histology : 

Cells of the cortex cerebri. Fibres. Neuroglia. Vessels. 
Situation of the cellular changes. The histology of 
secondary amentia. 

Morbid Anatomy : 

Gross developmental anomalies and pathological lesions. 
Hemiatrophy. Microgyria. Porencephaly. Deficiency of 
internal structures. Hydrocgprin.lng^ Encephalitis and 
meningo-encephalitis. ~lne sCull. 



CLASSIFICATION - 71-77 

Division of amentia into forms, degrees, and clinical varieties. 

Forms : 

Primary. Secondary. Delayed primary or developmental. 

Clinical Varieties : 

Of primary amentia : Simple , Microceph alic, Mongolian. 
Of secondary amentia : Amentia due 1 tu> -cerebral disease, 
amentia due to defective cerebral nutrition. 

Degrees : 

Feeble-mindedness (Children and adults). Imbecility. Idiocy. 
"Moral Imbecility." Definitions. 

Table of Classification. 



VI. PHYSICAL CHARACTERISTICS OF AMENTIA - 78-97 

Prevalence of physical defects in amentia. Stigmata of 
degeneracy. Table of anomalies. 

Anomalies of Anatomical Development : 

A. Nervous system. B. Special sense organs. C. Osseous. 
D. Muscular and cutaneous. E. Circulatory and re- 
spiratory. F. Alimentary. G. Urinary and generative. 

Anomalies of Physiological Function : 

Of special organs and of tissue in general. Mortality. Age 
periods of death. Causes of death, with table. • 



. MENTAL AND NERVOUS CHARACTERISTICS - 98-122 

Sensory : 

Vision. Hearing. Taste. Smell. Cutaneous. Muscle. Organic. 



Table of Contents xi 

CHAPTER PAGES 

MENTAL AND NERVOUS CHARACTERISTICS {continued) — 

Mental : 

Attention. Association and memory. Imagination. Ideation. 
Judgment and reasoning. Temperament. Emotion and 
sentiment. Volition. 

Motor : 

Varieties of movements. Anomalies of quantity and quality. 
Deficient. Excessive. Inco-ordinate. Speech. 




VIILJ FEEBLE-MINDEDNESS IN CHILDREN (MENTALLY 

DEFECTIVE CHILDREN) - - - 123-146 

Introductory account, with early inquiries into number and 
condition. Definition. Special schools and classes. In- 
quiries of Royal Commission of 1904. Number. Relative 
incidence in different area,s of the United Kingdom. Rela- 
tive incidence in town and country. Sex. 

Description : 

Physical. Nervous. Mental. Scholastic. The three grades of 
defect. Mentally defective compared with normal school- 
children. Varieties of mentally defective children. 

Diagnosis : 

Family history. Personal history. Present state. Differen- 
tial diagnosis from dull and backward children, delayed 
development, dullness due to ill-health, epilepsy, insanity, 
and imbecility. 

IX. FEEBLE-MINDEDNESS IN ADULTS - - 147-158 

Definition. Number. Sex. 

Description : 

Physical and mental characteristics. The " stable " type. 
The " unstable "type. Examples. 

X. IMBECILITY ------ 159-164 

Definition. Number. Sex. 
Description : 

Physical. Mental and nervous. Examples. 

XI. IDIOCY --.._. 165-172 

Definition. Number. Sex. 

Description : 

Partial or Incomplete Idiocy. — Physical. Mental and nervous. 

Apathetic and excitable idiots. Examples. 
Absolute or Complete Idiocy. 

Diagnosis of Idiocy and Imbecility. 



xii Table of Contents 

CjfArTEK PAGES 

XII.) CLINICAL VARIETIES OF PRIMARY AMENTIA - 173-193 
Division of primary aments into varieties. 
" Microcephalics : 

Introductory account and number. Causation. Pathology. 
Relation of brain weight to intellect. Physical, mental, 
and nervous condition. Examples. 

Mongolians : 

Introductory account and number. Causation. Pathology. 
Description of physical, mental, and nervous characteristics. 

The Compli cations of Primary ^jytttmtta ; 

Epilepsy. Paralysis. Hydrocephalus. Porencephalus. 

Sclerosis. Deaf-mutism. "* -■ 

^ 

NHL) CLINICAL VARIETIES OF SECONDARY AMENTIA 194-269 

-^Clinical differences between primary and secondary amentia. 

Section I. Amentia due to Cerebral Disease : 

1. Epileptic and eclampsic amentia. 

2. Vascular, toxic, and inflammatory amentia : Poren- 

cephalic, sclerotic, hydrocephalic. 

3. Syphilitic Amentia. . — 

4. Infantile Cerebral Degeneration. 

Section II. Amentia due to Defective Cerebral Nutri- 
tion. 

1. Cretinism : Endemic, sporadic. 

2. Amentia due to other nutritional defects. 

3. Amentia due to isolation and sense deprivation. 

XIV. IDIOTS SAVANTS ----- 270-280 

""^^/Description, with illustrative examples. The mechanical Genius 
of Earlswood Asylum. 

XV. THE AMENT AND SOCIETY— PAUPER AMENTS 281-292 
Location of the mentally deficient. The number of aments 
supported at the public expense. Feeble-minded in re- 
ceipt of parish relief. Idiots and imbeciles. Vagrants. 
Aments under inadequate care. Propagation by aments. 

XVft MORAL DEFICIENCY AND CRIMINAL AMENTS 293-309 
\ "^^-^Moral Deficiency : 

Latent moral defect. Its relation to amentia and to ' 
criminality. Habitual criminals and aments. 

Criminal Aments : 

Number. Facile type. Impulsive type. Morally defective 
or habitual criminal type. Illustrative cases. 

Criminal Responsibility of Aments : 

Conditions of responsibility : Defective knowledge, defective 
control, delusions. Civil incapacity. 



Table of Contents xiii 

CHAPTER PAGES 

XVII. INSANE AMENTS 310-323 

Sane and insane aments. Predisposition to insanity in aments. 
Borderland of amentia and insanity. Relative importance of 
predisposing and exciting factors. Insanity in the mild 
aments. Mania. Melancholia. Stupor. Alternating insanity. 
Delusional insanity. Recurrences. Dementia. General 
paralysis. Epileptic insanity. Insanity in imbeciles and 
idiots. Illustrative cases. 



XVIII. DIAGNOSIS AND PROGNOSIS - - - 324-331 

Diagnosis : 

In infancy. In childhood. In later years. 

Prognosis : 

Of the forms, varieties and degrees. 

XIXyTREATMENT AND TRAINING - - - 332-3 5 6 

y^medical and surgical treatment. 

Education : 

The general principles of education. Home training. School 
training. The senses, movement, intelligence, speech and 
scholastic. Industrial training. Moral training. 

(xW. CONCLUSION 357-362 

The necessity for training. Supervision and after-care. Pre- 
vention of propagation. Sterilization. Marriage. Eradi- 
cation. 



APPENDIX I. A TABLE OF NORMAL DEVELOPMENTAL 

DATA - 364, 365 

APPENDIX II. METHOD OF ESTIMATING THE TOTAL 

NUMBER OF AMENTS IN ENGLAND AND WALES 366-369 

APPENDIX III. THE LAW OF ENGLAND CONCERNING 
AMENTIA, with the Recommendations of the Royal 
Commission (1904) ----- 370-376 



INDEX 377 



LIST OF TABLES 



39 

77 



TABLE 

I. Showing the Total Number of Aments, and of Idiots, 
Imbeciles, and Feeble -Minded, per 1,000 Population, 
in Certain Districts of the United Kingdom 
II. Showing the Relative Incidence of Amentia in Certain 
Areas of the United Kingdom - 

III. Approximate Estimation of the Total Number of Aments, 

AND OF THE RESPECTIVE DEGREES, EXISTING IN ENGLAND 

and Wales on January i, 1906 - 

IV. Showing the Relative Incidence of the Degrees of 

Amentia in Certain Districts of the United Kingdom 

V. The Location of All Aments in Eleven Selected Areas 

of England and Wales - 

VI. Showing the Condition of 150 Aments with their 

Brothers and Sisters ----- 

VII. Classification of Amentia ----- 

VIII. Anatomical and Physiological Anomalies associated 

with Amentia - - - - - - 82 

IX. Relative Mortality of Aments and Non-Aments - 92 

X. Showing Age Periods of 1,000 Consecutive Deaths in 

Earlswood Asylum - - - - 92 

XL Showing the Percentage of Deaths to the Number of 
Patients in Residence at Earlswood Asylum over 
a Period of Seventeen Years - - - 93 

XII. Showing the Cause of Death in 1,000 Consecutive 

Deaths in Earlswood Asylum - - - - 94 

XIII. Consonantal Defects in Amentia - - - 121 

XIV. Showing the Percentage of Mentally Deficient Chil- 
dren to the Public Elementary School Population 
in Certain Districts of the United Kingdom - 126 

XV. Showing the Relation of Epilepsy to Amentia - 197 

XVI. Showing the Location of Feeble-Minded Persons in 

Urban and Rural Areas respectively - - 286 

XVII. The Number of Aments inadequately cared for - 287 

Appendix I. A Table of Normal Developmental Data - 364 



xv 



LIST OF FAMILY HISTORY CHARTS 

CHART PAGE 

I. Showing Good Heredity contaminated by Slight Alco- 
holic Heredity and Town Life - - - - 41 
II. Showing Good Heredity contaminated by Morbid He- 
redity -- - - - - -41 

III. Showing Good Heredity contaminated by Insane He- 

redity - - - - - - -42 

IV. Showing the Effect of Insane + Phthisical Heredity - 42 
V. Showing the Effect of Alcoholic and Insane Inheri- 
tance + Phthisical Inheritance - - - 43 

VI. Showing the Effect of Double Morbid Heredity - 43 

VII. Showing the Effect of Double Morbid Heredity - 44 

VIII. Showing the Effect of a Double Insane Inheritance 

+ Syphilis - - - - - - - 44 

IX. Showing the Effect of Consanguinity with a Tendency 

to Vascular Lesions of the Brain - - - 45 



LIST OF ILLUSTRATIONS 



PLATE FIGS. PAGE 

I. 1-8. Types of Brain Cells occurring in Amentia 

Frontispiece 
II. 9. Diagrammatic Sections of Frontal Cortex in 

Amentia, Dementia, and the Normal Brain - 6$ 

10. Schema for taking Cranial Measurements - 85 

TO FACE PAGE 

III. 11-16. Mentally Defective School-Children - - 128 

IV. 17-18. Primary Amentia, Feeble-Mindedness, Mentally 

Stable Type (Males) - - - - 150 

V. 19-20. Primary Amentia, Feeble-Mindedness, Mentally 

Unstable Type (Females) - - - 154 
VI. 21-22. Primary Amentia, Imbecility, Mentally Un- 
stable Type (Males) - - - - 160 
VII. 23-24. Primary Amentia, Imbecility (Females) - - 162 
VIII. 25-26. Primary Amentia, Imbecility (Males) - - 164 
IX. 27. Primary Amentia, Imbecility - - - 166 
28. Primary Amentia, Idiocy with Sclerosis - 166 
X. 29-30. Primary Amentia, Idiocy, Excitable Type - 168 
XL 31-32. Primary Amentia, Microcephalic Variety - 176 
XII. 33-34. Primary Amentia, Mongolian Variety - - 184 

XIII. 35-36. Primary Amentia, Mongolian Variety, Children 186 

XIV. 37-38. Primary Amentia, Mongolian Variety, Children 188 
XV. 39. Secondary Amentia due to Epilepsy - - 200 

40. Secondary Amentia due to Cerebral Lesion - 200 
XVI. 41. Secondary Amentia with Paralysis and Con- 
vulsions due to Infantile Lesion - - 214 
42. Secondary Amentia with Paraplegia due to 

Vascular Lesion at Birth - - - 214 
XVII. 43. Secondary Amentia with Epilepsy due to En- 
cephalitis in Infancy - - - - 218 

44. Secondary Amentia due to Encephalitis in 

Infancy - - - - - -218 

XVIII. 45. Secondary Amentia due to Sclerosis (so-called 

" Hypertrophy of the Brain ") - - 232 
xv ii 



xviii List of Illustrations 



FLATE FIGS. TO FACE PAGE 

XVIII. 46. Hydrocephalic and Microcephalic Imbeciles 232 
XIX. 47. Secondary Amentia due to Hydrocephalus, 

Child i£ Years Old - - - -236 

Female Microcephalic Aged 4$ Months - 236 

XX. 49-50. Secondary Amentia due to Syphilis - 246 

XXI. 51-52. Secondary Amentia, Cretinism - - 254 
XXII. 53. Secondary Amentia due to Congenital 

Blindness - - 266 
54. Secondary Amentia due to Deafness (the 

Genius of Earls'syood Asylum) - - 266 
XXIII. 55. Diagrammatic Life History of the Genius 

of Earlswood Asylum - - - 276 
XXI Y. 56. A Crayon Copy of the Picture " Bolton 

Abbey ------ 27S 

^;. A Fully Rigged Man-of-War - 278 
XX Y. 58. A Page of the Patient's Priyate Memoran- 
dum Book - 2S0 
59. The " Great Eastern " Steamship - - 2S0 
XXYI. 60. Criminal Ament - 296 
61. Insane Ament ----- 296 

XXVII. 62-63. Insane Aments - - - - -312 

XXVIII. 64-65. Insane Aments - - - - - 314 

XXIX. 66-67. Insane Aments - - - - - 316 



MENTAL DEFICIENCY 



CHAPTER I 

INTRODUCTION 

Literally, the term " mental deficiency " is just as applicable 
to a decay as to a non-development of the mental powers, to the 
dotage of old age or disease as to idiocy from birth; and it is still 
often used indiscriminately of either of these conditions. There 
is, however, a great difference between them. Mental defect 
occurring subsequently to mental development may be com- 
pared to a state of bankruptcy, and is more fittingly described 
as dementia (de, down, from ; mens, mind) ; whilst the person 
whose mind has never attained normal development may be 
looked upon as never having had a banking account, and this 
state is designated amentia (a, without ; mens, mind). In both 
of these, of course, there is literally mental deficiency ; but in 
view of the convenient and growing tendency to restrict this 
term to the latter class, I shall in this book use it in a specific 
sense as synonymous with " amentia." 

Mental deficiency, or amentia, then, is that state in which the 
mind has failed to attain normal development. But the ques- 
tion at once arises, What is'" normal " mental development ? 
for there is probably no quality in which human beings differ so 
much as the degree of their mental capacity. All civilized nations 
are composed of men of very varying grades of intellect, ranging 
from the genius of a Bacon, Newton, Kepler, Copernicus, Shake- 
speare, Plato, or Galileo, to the rustic simplicity of an agricul- 
tural Hodge ; and all of these come within the compass of the 

I 



Mental Deficiency 



normal Mind. Corresponding differences are present amongst 
barbarians and savages, and probably have always existed. 
What, then, is to be considered the standard, and how and where 
are we to draw a line which shall divide the normal from the 
abnormal, the least intellectually gifted members of normal 
mankind from the population which is mentally deficient ? 

It is not easy to do this, but I think that our best definition 
of the " normal " mind must be a degree of intellectual capacity 
sufficient to enable its possessor to perform his duties as a member 
of society in that position of life to which he is born. 

Fortunately for human progress, the mental capacity of many 
persons suffices for this, and more ; but where there is any falling 
short of this irreducible minimum, then I think we must say that 
the bounds of normal variation have been overstepped, and that 
a condition of incomplete development, or amentia, is present. 
We may thus define amentia as a state of mental defect from birth, 
or from an early age, due to incomplete cerebral development, in 
consequence of which the person affected is unable to perform his 
duties as a member of society in the position of life to which he is 
bom. 

It is not, however, to be assumed that amentia is merely a 
subtraction in varying degree from the normal. Although the 
contrary might be thought, nevertheless the two conditions do 
not merge into one another, and between the lowest normal and 
the highest ament a great and impassable gulf is fixed. Whilst 
the former is heavy, stolid, and uniformly dull-witted, he has 
yet sufficient common sense to look after his interests and hold 
his own in that environment in which Nature has placed him. 
The mildest ament, on the other hand, may show no apparent 
dullness ; he may even be bright and vivacious, and in some of 
his abilities immeasurably superior to the clodhopper. But the 
other faculties of his mind are not present in like proportion. 
Instead of harmonious working there is discord, and in the pos- 
session of that essential to independent existence — common 
sense — he is lacking, and the want can never be supplied. 

The difference has been well described by Sir J. Batty Tuke,* 
who says : " Where in theory the morbid and the healthy tvpes 
might be supposed to approach each other, we find in practice 

* Article " Insanity," " Encyclopaedia Britannica." 



Introduction 3 

that no such debatable ground exists. The uniformity of dull- 
ness in the former stands in marked opposition to the irregularity 
of mental conformation in the latter." 

The fact is that amentia is not merely a mental subtraction, 
but a distinct pathological condition which is produced by 
disease. The cerebral tissues concerned in Mind do not suffer 
from a uniform arrest of their development at a point which is 
inadequate for the needs of everyday life, but their whole growth 
and development is irregular. Even the function of the parts 
laid down is often imperfect and perverted, the total result being 
not only mental defect, but mental discord. 

The two other chief forms of mental disease are dementia and 
insanity. The fcrmer of these has already been referred to, 
and is the result of neuronic degeneration ; whilst " insanity " 
is the clinical manifestation of a disturbance or perversion of 
neuronic function, which may or may not terminate in degenera- 
tion, and which, as we shall subsequently see, is by no means 
incompatible with neuronic deficiency or amentia. 

The subject of amentia, therefore, whilst presenting many 
interesting problems to the physician, the pathologist, and the 
psychologist, has also a much wider interest and importance. 
Since in Man the predominant feature is Mind, and since it is 
by the development of this faculty that human progress has 
taken, and must take, place, it is clear that the question of 
its disease, and particularly of its defect, is one of supreme 
importance to the statesman, the sociologist, and the philo- 
sopher. 



1—2 



CHAPTER II 

INCIDENCE 

The enumeration of the mentally deficient population of any 
country is an extremely difficult matter, and there can be no 
doubt that most official inquiries, particularly those by means 
of the ordinary census, fall very far short of the truth. The 
reasons for this are numerous, the chief being the inability or 
unwillingness of parents to recognize mental abnormality, their 
total incapacity to distinguish between its various forms, and 
their not unnatural reluctance to proclaim its presence on a 
census paper. The milder forms of defect, which are at 
once the most important from a sociological aspect, and the 
most frequent, cannot possibly be detected by such means. 
For these reasons I am of opinion that the official returns of 
any country respecting the number of its aments are so unreli- 
able and incomplete that no useful purpose would be served by 
quoting them. 

Investigations of the Royal Commission of 1904. 

In this country, however, an enumeration has recently been 
made on quite another basis. In the year 1904 a Royal Com- 
mission was appointed to consider the existing methods of 
dealing with these persons, and the Commissioners decided that, 
before any practical scheme of administration could be formu- 
lated, it was imperative that they should obtain approximately 
accurate information as to the number and condition of the class. 
With this object, a series of personal investigations were insti- 
tuted on a considerable scale, and this is the first systematic 
attempt which has been made to obtain reliable data. It is 

4 



Incidence 5 

not too much to say that these inquiries have added enormously 
to our knowledge regarding the condition, manner of living, and 
environment of the aments of this country, besides making it 
possible to calculate their total number with a degree of accuracy 
hitherto unattainable. 

The method adopted by the Royal Commission consisted of a 
series of elaborate and searching inquiries by a number of medical 
men, to each of whom a selected area was assigned. The in- 
vestigator was instructed to visit personally all public elementary 
schools, poor-law institutions, charitable establishments, training- 
homes, reformatories, common lodging-houses, prisons, idiot 
asylums, hospitals, and, indeed, any establishment likely to 
harbour the mentally abnormal. Further, he was to see persons 
in receipt of Out-door relief, to apply to the clergy, medical prac- 
titioners, the police, charity organization societies, and similar 
agencies, and, in short, to make use of any and every channel 
which might help him to make the enumeration complete. 

It was not found practicable to investigate the whole of the 
country in this way, but, in order that conclusions applicable to 
the entire country might be drawn, a selection of certain typical 
areas was made. Altogether, there were examined nine areas in 
England, two in Wales, one in Scotland, and four in Ireland, 
having an aggregate population of 3,873,151. 

I shall again allude to many facts revealed by this inquiry in 
subsequent chapters ; but in this place some statistics regarding 
the ascertained number of aments may be quoted. 

The total number of aments varies in the different areas 
examined, and although to a slight extent this may be due to 
different personal equations, in many cases the difference is so 
great that it can only be regarded as the result of a real difference 
of incidence. This is shown in the following table : 



Mental Deficiency 



TABLE I.* 

Showing the Total Number of Aments, and of Idiots, Imbeciles, 
and Feeble-minded respectively, per 1,000 Population, in 
Certain Districts of the United Kingdom, according to the 
Investigations of the Royal Commission, 1904. 









Feeble-minded. 






Idiots. 


Imbe- 
ciles. 






Total 
Aments. \ 












Adults. 


Children. 




/ Manchester . . 


0-05 


0-32 


1-20 


2-IO 


3-74 




Birmingham . . 


0-09 


0-27 


1-70 


i-6o 


3-76 


Urban 


Hull .. 


0-02 


0-20 


o-55 


0-58 


1-35 


Glasgow 


0-07 


0-23 


0-32 


i-oo 


1-68 




Dublin 


0-19 


o-57 


1-20 


2-IO 


414 


.Belfast 


0-13 


0-63 


0-70 


0-97 


2 45 


( Stoke-on-Trent 
Industrial . . -j Durham 
I Cork .. 


0-21 


o-45 


2-IO 


I-IO 


3-96 


0-02 


o-34 


0-56 


0-56 


1-48 


0-07 


0-32 


0-16 


o-54 


110 


Mixed 1'Nottingham 


0-30 


o-66 


1-50 


1-20 


3-81 


Industrial | shire 












and J Carmarthen- 
Agricultural I shire 


o-59 


0-65 


0-51 


I- 20 


3-05 












( Somersetshire 


0-18 


i-oo 


2-IO 


I-IO 


4-54 


Wiltshire 


o-35 


0-69 


2-20 


0-90 


4-25 


Agricultural^ Lincolnshire . . 


0-44 


0-98 


1-40 


I'70 


4-68 


Carnarvonshire 


0-24 


0-58 


2-IO 


0-94 


3-96 


v Gal way- 


0-13 


i-oo 


I-OO 


2-20 


4-49 



It will be seen from this Table that, whilst the mean average 
incidence of total amentia in the sixteen areas is 3*28 per 1,000 
population, the variation ranges from a minimum of i*i, in the 
case of Cork, to a maximum of 4/68 in the case of Lincolnshire. 
The following table shows the areas grouped according to the 
prevalence of amentia : 



* The figures in this table slightly underestimate the true incidence 
for the reason that they do not include a small proportion of cases certified 
under the Lunacy Act. 



Incidence 



TABLE II. 

Showing the Incidence of Relative Amentia in Certain Areas 
of the United Kingdom. 



Low Incidence 

{under 3 per i.ooo 

Population). 


Mean Average Incidence 

(3/04 per 1,000 

Population) . 


High Incidence 

{over 4 per 1,000 

Population). 

Dublin 

Somersetshire 

Wiltshire 

Lincolnshire 

Galway 


Hull 

Glasgow 

Belfast 

Durham 

Cork 


Manchester 

Birmingham 

Stoke-on-Trent 

Nottinghamshire 

Carmarthenshire 

Carnarvonshire 



It is thus seen that the incidence of amentia in this country 
is far from being uniform ; that, in fact, great differences exist 
between areas in which there is little difference in physical, 
social, and industrial features. By means of the annual reports 
of the Lunacy Commissioners I have ascertained that the same 
applies to the incidence of insanity, and that, on the whole, 
there is a tolerably close correspondence between the relative 
extent of the two conditions (amentia and insanity). The 
cause of this differing prevalence of mental disease is not clear, 
and its investigation would probably necessitate very minute 
inquiries into the social, industrial, and hereditary condition of 
the people over a long period. Since, however, it relates rather 
to mental disease in general than to amentia in particular, it is 
beyond the scope of this work to do more than allude to it. 



The Number of Aments in England and Wales. 

If the incidence of amentia were tolerably uniform throughout 
the country, it would be a very simple matter to calculate the 
total number of affected persons from the figures revealed by 
this inquiry ; but, as we have seen, the incidence is very far 
from being uniform. It would also be quite easy could it be 
shown that the proportion of low to high prevalent areas in those 
examined were relatively the same as obtains in the whole 
country — if, in fact, we could be certain that we were dealing 
with a fair sample — but there is no a priori evidence that this 



S Mental Deficiency 

is so. Consequently the estimation is a somewhat complicated 
one. T believe, however, that by using the incidence of insanity 
as a standard we may arrive at a result which is approximately 
correct. All insane persons are not, of course, certified, but the 
returns of the Lunacy Commissioners regarding the number of 
the certified pauper insane may be accepted as a sufficiently 
accurate indication of the relative prevalence of insanity in the 
various union districts of England and Wales. The incidence 
of amentia, as already remarked, is, on the whole, directly pro- 
portionate to the incidence of insanity. Now, if we calculate 
the proportion per 1,000 population of the certified pauper 
insane in the eleven areas of England and Wales investigated 
by the Royal Commission of 1904, it works out at 3*15 ; but if 
w r e calculate the proportion per 1,000 of the certified pauper 
insane throughout the country (using in each case the returns 
of the Lunacy Commission* and the population according to 
the 1901 census f), it works out at 342. So that the mean 
average incidence of insanity, and consequently of amentia, in 
these areas is less than the mean average for the entire country, 
and this can only be due to the fact that the eleven areas examined 
contain a greater relative proportion of districts of low inci- 
dence. 

The actual number of aments in the country is therefore 
expressed by the equation : 

Aments : certified insane : : aments : certified insane 



in areas examined in England and Wales 

From which it follows that the total number of aments in Eng- 
land and Wales on January 1, 1906, was approximately 138,529 
persons, equivalent to (with an estimated population on that 
date of 34,349,435, according to the Registrar-General) 4-03 
persons per 1,000, or 1 in every 248. J 

* Total pauper certified insane in England and Wales on January 1, 
1906, according to the Sixtieth Report of Lunacy Commissioners = 
111,256. Total pauper insane in the areas investigated, as obtained from 
Table I., Appendix B, of same reports 7,328. 

f Population of England and Wales, according to 1901 census = 
32,525,716. Population of the eleven areas examined, according to 1901 
census = 2,321,567. 

% For further particulars and corrections, see " Appendix II. 



Incidence 9 

The Number of Persons suffering from Each of the Three Degrees 
of Amentia in England and Wales. 

This may be calculated in a similar manner to the foregoing, 
and the results arrived at are shown in the following table : 

TABLE III. 

Approximate Estimation of the Total Number of Aments, and of 
the Respective Degrees, existing in England and Wales on 
January i, 1906. 

{Estimated Total Population according to Registrar-General, 34,349,435.) 

Idiots .. .. .. 8,654 persons, or 0-25 per 1,000 population. 

Imbeciles . . . . 25,096 ,, 0-73 

Feeble-minded j^l 15 54 '" 4 * " I<57 

(Children 50,665 ,, 1-47 



Total .. 138,529 ,, 403 

(or 1 person in every 248) 

The Relative Incidence of the Three Degrees of Amentia. 

It is seen from Table III. that idiots are decidedly the least 
numerous of the three degrees of amentia ; that imbeciles occur 
next in frequency, being nearly three times as plentiful ; whilst 
the number of the feeble-minded is more than three times as 
great as the idiots and imbeciles combined. In other words, 
taking the country as a whole, there are in every 100 aments : 

Idiots. Imbeciles. Feeble-minded. 



Adults. Children. 

6 18 39 37 

Or, in every 10,000 population there are (taking the nearest 
whole numbers) : 

Idiots. Imbeciles. Feeble-minded. Insane. 



Adults. Children. 

2 7 15 14 36 

* It seems probable that the excess of adult over juvenile feeble- 
minded is due to the inclusion in the former group of 4,450 patients in 
asylums. The majority of these belong to the mildest type of mental 
defect, and are detained on account of insanity or epilepsy. If seen during 
the school period, they would probably be looked upon as doubtful, and 
given the benefit accordingly. Their condition becomes obvious when 
competition with the outside world has to be faced. 



IO 



Mental Deficiency 



There are, however, certain variations in the relative incidence 
of these degrees of amentia which seem to be referable to the 
environment, and to these brief allusion must be made. It is 
found that the severer degrees of defect (idiots and imbeciles) 
are both relatively and absolutely much more numerous in 
agricultural than in urban and industrial areas, whilst in the 
case of the juvenile feeble-minded (mentally defective children) 
the results are reversed, these being both relatively and absolutely 
more numerous in urban than in agricultural areas. The actual 
figures will be seen by reference to Tables I. and IV. 



TABLE IV. 

Showing the Relative Incidence of the Degrees of Amentia in- 
Certain Districts of the United Kingdom. Calculated from 
the Returns of the Royal Commission, 1904. 





In 


Every 100 Aments 






there 


are — 




Imbeciles. 


Feeble-minded. 




Idiots. 












Adults. 


Children 




'Manchester 


i'5 


8-6 


31-0 


57-o 




Birmingham 


2-5 


7-2 


45-0 


44-0 


Urban 


Hull 


i-5 


7-8 


44-0 


46-0 1 




Glasgow 


4'3 


13-7 


19-4 


62-6 ; 




Dublin 


4-6 


14-0 


30-0 


5i-3 




.Belfast 


5'3 


25-9 


29-0 


39-5 ! 


f Stoke-on-Trent 
Industrial . . J Durham 

[Cork 


5'3 


n-4 


53'0 


30-0 ! 


i-5 


23-0 


37-o 


3 8-o ! 


67 


29-0 


15-0 


49-0 ! 


Mixed Indus- ) « T „. , 
trial and ' Nottinghamshire .. 
Agricultural J Carmarthenshire . . 


8-i 


17-0 


41-0 


32-0 


14-0 


22-0 


18-0 


,44-o 


f Somersetshire 


4-0 


23-0 


47-0 


25-0 


Wiltshire 


8-3 


IS-O 


52-0 


23-0 


Agricultural - Lincolnshire 


9-5 


21-0 


31-0 


37-o 


Carnarvonshire 


6-o 


I4-0 


S5-o 


24-0 


l^Galway 


2-9 


22-8 


23V 


50'5 



Incidence 1 1 

Inasmuch as the inquiries from which these statistics are com- 
piled excluded all persons certified under the Lunacy Act, there 
is a slight fallacy in these figures. In order to ascertain the 
extent of this, I made a special investigation as to the total 
number of aments (certified and uncertified) in a few of the 
areas examined. The results show that the proportion excluded 
does not appreciably alter the relative incidence as shown in 
Table IV. The cause of this difference of relative incidence will 
be discussed in a subsequent chapter. 



Incidence of Amentia relative to Insanity. 

It has been stated that the incidence of amentia is directly 
proportionate to that of insanity, and on the whole this is true ; 
for it is found that where insanity is rife amentia is also prevalent, 
and, conversely, where there is little insanity there is little 
amentia. The inquiries of the Royal Commission show, how- 
ever, that the relative incidence of these two forms of mental 
disease is subject to slight variations according to the environ- 
ment, and, generally speaking, amentia would appear to be 
relatively more prevalent in rural, and insanity in urban, districts. 

The aments are a slightly more numerous class than the 
insane, for a calculation of the total number of the latter (un- 
certified as well as certified) shows that the approximate number 
of this class in England and Wales on January I, 1906, was 
125,827, corresponding to 3*66 per 1,000 population, or to 
1 person in every 273. 

The approximate total number of persons suffering from all 
forms of pronounced mental disease (amentia, insanity, and 
dementia) in England and Wales is, therefore, 264, 356, equivalent 
to 7'6o, per 1,000, or 1 person in every 130. 



Location. 

In order to give a general idea as to the location of these 
aments I append the following table (V.), which shows the 
situation of the 8,079 persons revealed by the inquiries of the 



12 



Mental Deficiency 



Royal Commission, together with those not so included on account 
of being certified under the Lunacy Act : 



TABLE V. 

Location of all Aments in Eleven Selected Areas of England 
and Wales. Mainly based upon the Inquiries of the Royal 
Commission, 1904. 





Feeble-minded. 


Imbe- 
ciles. 


Idiots. 


Totals. 


Juvenile. 


Adult. 


Persons. 


Per Cent. 


(a) In institutions : 

Poor Law- 
Charitable* 
Idiot asylums . . 
Lunatic asylums 
Prisons 
Inebriate homes 

(b) In receipt of out- 
door relief 

(c) Not receiving re- 
lief : 

1 . Friends able to 
make partial or 
full permanent 
provision 

2. Friends unable 
to make per- 
manent provi- 
sion 

(d) In public elemen- 
tary or special 
schools 


83 

34 
3 

10 

50 

217 

2,936 


1,387 

115 

22 

366 

197 

17 

358 

234 

926 

II 


152 

60 
276 

237 

138 

434 

74 


47 1 

15 
92 

103 

72 
147 


2,866 

708 

494 
1,724 
3,021 


32-5 

8-o 

5-6 
19-5 
34'2 


Totals 


3.333 


3^33 L37I 


476 


8,813 





* Charitable institutions are composed as follows : 

Institutions for the blind, deaf, crippled, epileptic, and defective, 

21 persons. 
Training and rescue homes, penitentiaries, etc., 128 persons. 



Incidence 



13 



Incidence with Regard to Sex. 

The sex of the 12,120 aments discovered in sixteen areas of the 
United Kingdom is as follows : 



Idiots. 


„ , Feeble-minded. 
Imbe- 


Totals. 

6,685 
5.435 


dies. 

Children. 


Adults. 

2,179 
2,112 


Males . . . . . . 303 

Females . . . . 282 

j 


959 3.244 
848 ; 2,193 



It is thus seen that, considered either in regard to each degree 
or collectively, there is a slight preponderance of the male sex, 
the relative proportion of males to females being practically as 
6 to 5. It is probable that of all aments born a considerably 
greater proportion than this are of the male sex ; but that the 
number of these is subsequently diminished by a relatively 
higher infantile mortality. 

That a greater number of aments are to-day resident in institu- 
tions than was the case a generation back is, I think, incontestable, 
and the exigencies of modern life must undoubtedly lead to an 
increase of this number in years to come ; but as to whether the 
condition is or is not more prevalent than formerly, or as to 
the relative incidence in different countries, we have no data 
upon which to form an opinion. It is quite clear, however, 
from the statistics here given, that even on account of its present 
prevalence the condition is one deserving of the gravest con- 
sideration. 



CHAPTER III 

CAUSATION 

Amentia has been denned as mental deficiency due to imperfect 
or arrested cerebral development, and in the investigation of 
its causes we have to inquire into all the influences concerned 
in embryonic development, as well as those affecting the growth 
of the brain after birth. In other words, we must ascertain as 
completely as possible the family and the early personal history 
of these afflicted persons. Now, such an inquiry is by no means 
easy ; it requires not only a considerable amount of special know- 
ledge in order rightly to interpret the accounts furnished by 
unscientific, and often ignorant, persons, but it also demands much 
patience and tact. The not unnatural reluctance evinced by the 
majority of persons to admit the presence of mental unsound- 
ness in the family often leads to the deliberate withholding of 
information, whilst a strongly prejudiced view of the importance 
of some one particular factor may cause all others to be ignored, 
and so greatly mislead the investigator. I do not think there 
is any disease in which, in the minds of parents and relatives, 
the post hoc ergo propter hoc opinion figures more largely. 

Nevertheless, a very large number of cases have now been 
examined, and although the opinions of inquirers differ slightly 
as to their relative importance, there is a very general agreement 
as to the main influences which are responsible for the imperfect 
condition of the brain cells. 

It would be too large a task to refer to all the work which 
has been done in this direction, even in this country alone ; and 
as I have myself devoted much time to the subject, and have 
investigated the antecedents of a large number of these patients, 
I propose to give my own results, alluding where necessary to 

14 



Causation 15 

the points upon which they differ from those of other inquirers. 
My reason for doing this is that the question of causation not 
only involves the ascertainment of facts, but the careful analysis 
and consideration of such facts in conjunction with the clinical 
features of the patients, and I feel more competent to do this 
with data personally collected than with those obtained by other 
persons. My investigations* embrace patients seen in the 
asylums of the London County Council, the special institutions 
at Darenth and Earlswood, the Littleton Home for Defective 
Children, and my own private practice, and they include every 
grade and variety of amentia. This point is important, because 
the type of case varies much in different institutions, and 
statistics, however numerous, which are confined to any one 
institution are apt, on that account, to be misleading. 

In dealing with this subject, it has been the usual custom for 
writers to divide the cases into two groups — " congenital " 
and " acquired.." Such a division is open to the objection that 
what would be termed a congenital condition may really be due 
to a factor of the environment, and acquired in utero. The real 
question is the relative parts played by heredity and environ- 
ment. Accordingly, I have thought it better to use the terms 
intrinsic and extrinsic. Intrinsic factors are hereditary influ- 
ences which modify the germinal plasm before conception takes 
place, and the form of amentia so produced may be termed 
primary. Extrinsic factors are those conditions of the environ- 
ment which affect the development of the brain (and body) 
either whilst yet within or without the uterus, and in this case 
the amentia may be termed secondary. The various etiological 
factors will, therefore, be discussed in the following order : 

{A) Intrinsic — Heredity. 

1 . Disease of the Nervous System. 

2. Alcoholism. 

3. Tuberculosis. 

4. Syphilis. 

5. Consanguinity. 

6. Age of Parents. 



* An analysis of 150 of these was given in my article on " Amentia " in 
Mott's " Archives of Neurology," vol. i. Nearly another hundred have 
since been investigated, with practically identical results. 



1 6 Mental Deficie 



ncy 



(B) Extrinsic — Environment. 

C i. Abnormal Conditions of the Mother during Preg- 

(a) Before Birth - nancy — (i) Mental, (2) Physical. 

[ 2. Injuries to the Fcetus. 

( 1. Abnormalities of Labour. 

(b) During Birth J 2. Primogeniture. 

I 3. Premature Birth. 



(c) After Birth 



Traumatic. 
Toxic. 



\ 3. Epileptic and Infantile Convulsions. 
I 4. Malnutrition. 



(A) Causes Inherent in the Germinal Plasm — Heredity. 

1. Disease of the Nervous System. 
It is agreed by all who have studied this question, that the 
most frequent cause of amentia is some ancestral pathological 
condition — morbid heredity. It is also agreed that the com- 
monest form of morbid heredity is disease of the nervous system. 
In a small proportion of cases the antecedent nervous disease 
consists of cerebral haemorrhages, paralysis, or various neuroses ; 
but in the great majority it is insanity, dementia, or epilepsy. My 
own inquiries showed that over 80 per cent, of persons suffering 
from the severer grades of amentia were the descendants of a pro- 
nounced neuropathic stock. In 64 per cent, the heredity was in 
the form of insanity or epilepsy ; whilst in 18 per cent, it consisted 
of a marked family tendency to paralysis, cerebral haemorrhages, 
or various neuroses and psychoses. Somewhat similar results, 
showing the great prevalence of this factor, have been obtained 
by other investigators. For instance, in England it was found 
by Beach and Shuttleworth* that insanity, epilepsy, and allied 
neuroses were well marked in the ancestors of 42 per cent, of 
the patients they examined ; but Dr. Caldicott considers that 70 to 
75 per cent, have neuropathic antecedents. In America a Com- 
mission appointed by the Legislature of Connecticut found 
neuropathic heredity to be the undoubted cause in 43 per cent. 
In Germany Kochf came to the conclusion that it accounted for 

* Beach and Shuttleworth, Clifford Allbutt's " System of Medicine," 
vol. vii. 

t J. L. A. Koch, " Zur Statistik der Geisterkrankheiten in Wi'irtemberg, 
und der Geisterkr. iiberhaupt," Stuttgart, 1878. 



Causation 17 

60 per cent, of cases. In Switzerland (Canton of Berne) the 
census of 1893 showed that heredity was present in 55 per cent, 
of idiots ; whilst in Norway Ludwig Dahl found it to occur in 
50 per cent, of cases. 

It is seen that my own results are considerably higher than those 
obtained by most other observers, and it is necessary to explain 
the discrepancy. I believe it to be entirely a question of the 
method adopted. Most statistics relating to this subject have 
been compiled from case-books or official returns, and although 
by this means an immense amount of material is available, the 
details must necessarily be lacking in the accuracy and com- 
pleteness obtainable by a personal inquiry. Again and again 
have I discovered, by a little questioning, a well-marked history 
of insanity, of which no record whatever existed in the official 
case-book ; and it is my opinion that, although statistics based 
upon these may be of value as showing the relative importance of 
the different factors, they are practically valueless as an indica- 
tion of the precise extent to which these factors occur. 

It was the recognition of the incomplete and unsatisfactory 
details in the case-books, including some of those which have 
formed the basis for previous generalizations on this matter, 
which decided me to conduct an independent and personal 
inquiry into the causation of amentia. Unfortunately, the 
taking of a reliable family history involves much time and 
trouble. It is essential to gain the confidence of the relatives, 
and it is often necessary to interview several members of the 
family before all the requisite details can be elicited. More- 
over, family histories can rarely.be considered satisfactory unless 
they include particulars of three generations. For these reasons 
a personal inquiry of this kind can only be based upon a com- 
paratively small number of cases ; but what is lost in quantity is 
more than compensated for by accuracy and wealth of detail. 
As a matter of fact, although I have had access to several thou- 
sands of cases, in only a little over 200 were the details suffi- 
ciently complete to be of use. 

With regard to this morbid neuropathic heredity, the following 
additional facts may be cited : of 124 patients with neuropathic 
heredity, it was present in the direct line only in 58 ; in the 
collaterals only in 26 ; and in both direct and collaterals in 40 

2 



1 8 Mental Deficiency 

cases. It was present on the paternal side only in 61 ; on the 
maternal only in 39 ; and on both sides in 24 cases. 

It is seen from these latter figures that paternal is more common 
than maternal inheritance. Voisin found the reverse to be the 
case. It is therefore probable that a sufficiently large series 
of cases would show that there was little difference in this 
respect. In my cases the transmission occurred equally to the 
same and to the opposite sex. 

2. Alcoholism. 

This is the hereditary factor next in importance, and in my 
own series of cases a pronounced history of family alcoholism 
occurred in no less than 46*5 per cent. It is to be remarked, 
however, that in five-sixths of these definite neuropathic heredity 
was present in addition ; whilst in most of the remainder there 
were other morbid influences. 

The results obtained by other inquirers are somewhat divergent. 
Beach and Shuttleworth found a history of alcoholism in but 
16*38 per cent, of their cases ; Kerlin (Philadelphia) in 38 per 
cent. ; and Bourneville (Paris) in 62 per cent. Howe (America) 
found that in nearly 50 per cent, of idiots the parents were 
habitual drunkards. On the other hand, Looft (Norway) found 
it present in but 37 per cent., and Kind (Hanover) in only 
11 per cent. 

There can be little doubt that long-continued, excessive 
indulgence in alchohol has a considerable effect upon the germ and 
sperm cells, and that it results in an impairment of the nervous 
system of the offspring. In fact, I believe that such psychoses 
as hysteria, migraine, epilepsy, etc., are often due to this cause.* 
In my experience, however, alcoholism is rarely the immediate 
and sole cause of amentia, although where other factors exist — 
particularly neuropathic heredity — it is a most important con- 
tributory agent. 

But there is another mode of action which has to be con- 
sidered — namely, the direct effect of alcohol upon the embryo. 
This is not hereditary, but environmental ; it will, however, 

* Interesting evidence on this point is furnished by a laborious research 
conducted by Dr. Crothers of Connecticut, U.S.A., and published in the 
Quarterly Journal of Inebriety, January, 1901. 



Causation 1 9 

be convenient to refer to it in this place. The ingestion of 
alcohol is very speedily followed by its appearance in the blood, 
consequently the alcohol imbibed by a pregnant woman very 
soon comes into close contact with the tissues of the embryo. It 
has been conclusively shown by numerous experiments* that 
alcohol exerts a most marked baneful influence upon growing 
protoplasm, and the systematic abuse of alcohol during gestation 
is liable to be followed by decidedly injurious consequences to 
the offspring. These consequences are often widespread, but 
anomalies of mental action are the most frequent, as they are 
certainly the most important. Occasionally actual idiocy may 
result, of which several instances have been recorded. 

Some authors have endowed one particular moment — that of 
conception — with quite phenomenal possibilities ; and Langdon 
Down, Sabatier, Quatrefages, Lucon, Morel, Bourneville, and 
several other writers, are of opinion that idiocy is a common 
sequence of drunkenness at this time. Accurate information on 
such a point is, of course, very difficult to obtain, and it is not 
easy to eliminate other factors. Drunkenness at such a moment 
is more likely to be an incident in a life of intemperance than 
a solitary lapse, and in many cases it is probably actually sympto- 
matic of a neuropathic diathesis. Perhaps the influence of this 
factor per se is best judged by the instances mentioned by 
Ireland, f in which in some parts of Scotland whole villages of 
the lower classes get drunk at New Year time, or where the 
herring fishermen have a carouse upon their return to port. 
Dr. Ireland states that it has never been noticed that the resulting 
children are idiotic. I have histories of idiots conceived under 
such circumstances, but so I have of normal children ; and my 

* It was shown by Fere of Paris that the effect of the vapour of 
alcohol upon incubating eggs was to produce 63 per cent, of normal 
births, 16 per cent, of incompletely developed embryos, and 21 per cent, 
of monstrosities and chickens of "idiotic and imbecile grade." If the 
experiments were made with alcoholic solutions of absinthe, the effects 
were still more marked, there being but 25 per cent, of normal births, 
31 per cent, of incompletely developed, and 44 per cent, of abnormal and 
defective chicks. (" Comptes Rendus, Societe de Biol.," Paris, vol. lii.) 

For further particulars as to the effect of alcohol, see Horsley and 
Sturge, "Alcohol and the Human Body," 1907; also a very interesting 
paper on "The Problem of Heredity," by W. L. Andriezen, Journal of 
Mental Science, January, 1905. 

t W. W. Ireland, " Mental Affections of Children," 1898. 

2—2 



2o Mental Deficiency 



opinion is that, whilst this may be a cause in some cases, the 
number of such is — in this country, at any rate — exceedingly 
small. 

3. Tuberculosis. 

I believe that this factor is but rarely the direct and sole cause 
of amentia ; but my observations show that, like alcoholism, it 
has a very important indirect and contributory influence. Its 
indirect effect is seen in its undoubted potency to produce the 
milder forms of nervous instability in the offspring, such as 
migraine, hysteria, and mild epilepsy ; whilst its importance as 
a contributory agent is shown by the large proportion of aments 
who come of a tuberculous stock. I found that in the families of 
34 per cent, of aments there was a pronounced tendency to 
tubercular lesions. Beach and Shuttleworth found the same 
in close on 30 per cent, of their cases ; Langdon Down in 22*5 per 
cent., Kerlin in 56 per cent. In four-fifths of my cases, however, 
this tuberculous diathesis was associated with a neuropathic 
inheritance, and in the remaining fifth other conditions — usually 
alcoholism — were also present. Some additional evidence as 
to the prevalence of a tubercular diathesis in the mentally 
defective is afforded by the large number of these persons who 
succumb to this disease. Ireland estimates the proportion as 
fully two-thirds of all cases, and although in many, or most of 
them, the general deficiency in mental and bodily vigour may 
increase their susceptibility to the action of the specific bacillus, 
I think the large death-rate from this cause warrants us in 
saying that there must be an inherited predisposition beyond 
the ordinary. 

I regard these three morbid ancestral conditions — namely, 
disease of the nervous system, alcoholism, and consumption — as 
being far and away the most frequent causes of mental defect. 
The two latter appear to me to be rather remote than immediate 
in their action, their effect being to initiate the neuropathic 
diathesis, which (if unchecked) eventually culminates in amentia. 
It is comparatively rarely that they give rise to actual mental 
deficiency in the immediately succeeding generation, although 
they may do so in some cases. In my own series there were 
7-5 per cent, in whom no other cause was discoverable. In four- 
fifths of these the ancestry was literally saturated with both 



Causation 2 1 

alcohol and consumption, in the remainder with alcohol alone. 
Most of these patients suffered from a mild degree of imbecility 
accompanied by epilepsy. 

On the other hand, where a neuropathic inheritance exists on 
one side, the presence of either of these factors appears to exert 
a most potent contributory influence. As showing the extent to 
which they occurred in combination, it may be stated that, of 
124 patients coming of neuropathic stock, 28 had in addition an 
alcoholic, and 15 a tubercular, heredity; whilst in 19 both of 
these contributory causes were present. 

4. Syphilis. 

Most observers are agreed that syphilis alone is not a frequent 
cause of amentia. Fletcher Beach found it present in but 1 -17 per 
cent, of the 2,400 pauper aments he examined from the London 
area. Langdon Down and Shuttleworth found it in about 2 per 
cent, of cases, and in my own series it occurred in 2*5 per cent. 
It is probable, as stated by Mott, that " there would undoubtedly 
be a considerably larger proportion of defective children from 
this cause were it not for the very high rate of sterility, mis- 
carriages, stillborn and short-lived offspring that it produces." 

The action of syphilis in these cases may be truly hereditary — 
namely, by impairing the vitality of the germ or sperm cells, so 
that perfect development cannot take place. Fournier* has 
shown that this devitalization is by no means an uncommon 
result, but inquiries show that in cases of amentia there are 
generally other factors, especially neuropathic heredity, present 
in addition to the syphilis. 

On the other hand, syphilis may be " inherited " without 
being hereditary in the sense in which we have been speaking, 
and cases of " congenital " syphilis are of this nature. The 
actual disease is here transmitted to the child through the 
maternal tissues. The condition is not truly intrinsic, but 
environmental ; yet we may, as a matter of convenience, refer 
to it here. Children thus suffering from inherited syphilis 
present the characteristic lesions of that disease ; but the pro- 
portion who are in consequence mentally defective appears to 

* Fournier, " Les Affections Parasyphilitiques," 1894. See also Mott, 
" Heredity and Disease," British Medical Journal, October, 1905. 



22 Mental Deficiency 

be small. As a result of my examination of over 1,000 idiots 
and imbeciles of varying grades in Darenth Asylum, I found only 
about o - 5 per cent, whose condition could be attributed solely to 
syphilis. It is also clear, from a study of the numerous cases of 
congenital lues which may be seen in the out-patient department 
of any large hospital, as well as from the number of adults 
marked with the characteristic signs, that a normal mental 
development is quite compatible with the existence of this disease. 
Where amentia does result, it is generally because other factors 
are present in addition. 

It has been suggested by Dr. Sutherland that syphilis is a fre- 
quent cause of that variety of defect known as "Mongolism." 
My experience, resulting from the careful investigation of many 
family histories and patients of this type, does not confirm this 
view. 

Alcohol, tubercle, and syphilis are probably by no means 
the only poisons which have a devitalizing effect upon the 
germ and sperm cells, and which therefore contribute to arrest 
and anomalies of development. They are, however, the most 
prevalent, and on that account the most important. As an 
example of the action of other poisons, reference may be made to 
lead, some striking figures regarding which are furnished by 
Constantin Paul.* This observer relates that out of thirty-two 
pregnancies in which the father suffered from lead-poisoning, the 
mother being free from that condition, there were twelve stillborn 
and seventeen deaths under the age of three years, another one 
dying later in childhood ; whilst only two were found to be alive, 
aged twenty years and twenty-one months respectively. 

5. Consanguinity. 

The statement has been frequently made that the marriage 
of near blood relations is attended with disastrous results to 
the physical and mental condition of the offspring, and this 
factor used to be alleged, and is now considered by many persons, 
as a prevalent cause of idiocy. Certainly in some such marriages 
the consequences upon the offspring are appalling, as has been 
well shown by numerous writers. On the other hand, there are 
instances where repeated intermarriage has taken place for many 
* Constantin Paul, Plumbism and the Foetus," Paris, 1861. 



Causation 23 

generations without the slightest untoward result. Thus, Voisin, 
who investigated the offspring of forty-six consanguineous mar- 
riages in the commune of Batz, where intermarrying had been 
the rule for several generations, says that " insanity, idiocy, and 
deaf-mutism are unknown "; and the same author could not find 
consanguinity the cause of mental deficiency in a single case at 
the Bicetre and Salpetriere. Huth* also is of opinion that this 
practice is not attended with harm if the family is healthy, and 
instances the inhabitants of Pitcairn and Iceland in support of 
his statement. George Darwin j arrived at a similar conclusion. 
The crux of the whole question is the presence of morbid heredity, 
not of consanguinity, and I believe the result to be entirely 
dependent upon the presence or absence of a constitutional 
taint. Should such be present, it will, of course, tend to be 
accentuated, and the effect upon the offspring may be disastrous. 
In its absence, however, I doubt whether any untoward result 
is likely to follow, and I certainly do not think that amentia 
will arise. As a matter of fact, a considerable amount of inter- 
marrying still takes place in certain localities of our own country, 
such, for instance, as inaccessible islands in the North of Scot- 
land and out-of-the-way rural districts ; but I know of no statistics 
showing that in these cases it has been responsible per se for the 
occurrence of mental deficiency. At the same time there are 
many physiological reasons against the practice, and it is not one 
to be advocated. 

In my opinion, therefore, the statement that consanguinity is, 
in itself, an important cause of amentia is one not supported by 
facts. In my own series of cases I found that only 5 per cent, 
of defectives were the offspring of blood relations, and in all of 
these a pronounced neuropathic heredity was present. A simi- 
larly small percentage is revealed by several other inquirers. 
Thus, Beach and Shuttleworth found consanguinity in 4*2 per 
cent., Down in 7 per cent., Kerlin in 7 per cent., and, in fact, 
the result of careful research is decidedly to discount this factor 
as a cause of amentia. Langdon Down, indeed, says : " I am 
by no means sure that by a judicious selection of cousins the race 
might not be improved." 

* Alfred Huth, " Marriage of Near Kin," London, 1875. 
f G. Darwin, Journal of the Statistical Society, June, 1875. 



24 Mental Deficiency 

6. Age of Parents. 

There are reasons for thinking that the age of the parents at 
conception is not without influence upon the vitality of the child. 
Thus Korosi,* as a result of the investigation of 24,000 unselected 
individuals, came to the conclusion that the children of fathers 
below twenty and above forty years are weaker than when the 
fathers are between these ages ; also that the children of mothers 
over forty years of age are weaker than those born when the 
'mother is below this age. Matthews Duncan f was of opinion 
that premature and late marriage were influential in the pro- 
duction of idiocy, and Langdon Down J found that in 23 per 
cent, of idiots there was a disparity of more than ten years in 
the ages of the parents. Amongst my own patients a similar 
disparity existed in 4 per cent, of cases, in all of them the father 
being the elder. In one case the difference in age was as much 
as thirty-two years. In all these families, however, a well- 
marked neuropathic diathesis was present, and as I have know- 
ledge of several cases in which a similar difference existed with- 
out morbid heredity, where the offspring is perfectly healthy, 
I am of opinion that the influence of such a condition is, in itself, 
really infinitesimal. 

(B) Causes Extrinsic to the Germinal Plasm — Environment. 

The abnormal factors of the environment may most con- 
veniently be referred to under the three headings — Before, During, 
and After Birth. 

Those acting before birth are mostly referable to some un- 
healthy mental or physical condition of the mother during 
pregnancy, although an actual injury to the foetus may also 
occur during this time. During birth they chiefly relate to the 
various abnormalities attending labour, and in this place refer- 
ence will also be made to primogeniture and premature birth. 
After birth the factors are either traumatic, toxic, convulsive, 
or some disturbance profoundly influencing nutrition. 

There is no doubt that a history of one or other of these factors 

* Korosi, Transactions of the International Congress of Hygiene, 
London, 1891, vol. x. 

f Matthews Duncan, Lancet, January and March, 1883. 

X Langdon Down, " Notes of One Thousand Cases of Idiocy." 



Causation 25 

can be elicited in a considerable number of cases of amentia. 
In my own series of cases they were present in no less than 
65 per cent. There is, however, much difference of opinion as 
to their importance as a cause of this condition. 



1. Before Birth. 

I. Abnormal Conditions of the Mother during Pregnancy. — 
The unhealthy state of the mother may be either mental or 
physical. The former embraces worry, sudden shock or fright, 
and the much-debated question of maternal impressions ; whilst 
the latter may be due to the presence of actual disease, or to a 
general state of imperfect health independent of any specific illness. 
Perhaps in some instances these physical conditions may 
operate upon the germ cells before conception, but it is con- 
venient to refer to them under the heading of environment. 

I found one or other of these abnormal conditions to be present 
in about one-fifth of the cases I examined, but in most of them 
there was, in addition, a pronounced morbid heredity, generally 
insanity or epilepsy. As a consequence I have come to the 
conclusion that, although these conditions may have an im- 
portant contributory influence, it is with extreme rarity that 
they can be considered to be the sole cause of mental defect. 

I am of opinion that the bodily, rather than the mental, state 
of the mother is of most importance to the developing embryo, 
and a condition of general physical prostration or malnutrition is 
more commonly present in cases of amentia than is actual disease. 
In poorer people especially this malnutrition can often be directly 
traced to an insufficiency of food during this period, due to the 
fact of the bread-winner of the family being out of work, although 
it is probable that frequently recurring pregnancies may so lower 
the mother's vitality as to produce a similar result. 

I have already stated that the presence of alcoholism, tuber- 
culosis, and syphilis in the mother constitute an adverse environ- 
ment, and may in that way decidedly interfere with the normal 
development of the offspring. Other poisons may so act, and 
one of the chief of these is lead. Rennert* states that many of 
the women employed in the pottery factories of Germany suffer 

* Rennert, American Journal of Obstetrics, October, 1882. 



26 Mental Defic 



lency 



from a form of plumbism, which gives rise to frequent abortions, 
deaf-mutes, and macrocephalics. It is possible that ecbolics 
may have a similar effect, and it is even stated that in America 
the use of these drugs is responsible for a considerable number 
of cases of feeble-mindedness. Moreover, the influence of a toxic 
environment upon the offspring has been experimentally demon- 
strated by Fere in the interesting series of investigations upon 
eggs already referred to. It must, however, be emphasized that 
cases of amentia resulting from these causes are relatively rare, 
and that in the large majority of defectives an abnormal con- 
dition of the mother during pregnancy has a contributory or 
determining influence only. 

But in cases in which hereditary neuropathic predisposition 
is but slight, contributory influences of this kind may become 
of considerable importance, and may make all the difference 
between a development of the nervous system compatible with 
the needs of everyday life and one of mental deficiency. As 
will presently be seen, these and similar contributory factors 
explain why it happens that an idiot may be born into a family 
of which the other members of the same generation show no 
obvious mental or physical deterioration. 

Illegitimacy has been credited with the causation of amentia. 
It is no doubt responsible for a very high proportion of infantile 
deaths,* and statistics show that this is on account of the adverse 
environment in such cases, but I do not think it is ever in itself 
a direct cause of mental defect. 

With regard to the much-debated question of maternal im- 
pressions, without entering into this subject in any detail, it can 
be said that both these and the sudden frights and shocks which 
are often alleged to be the cause of the patient's condition really 
have very little influence. So far I have been unable to dis- 
cover a single case of this nature in which hereditary influences 
(commonly insanity) were not forthcoming upon a careful inquiry 
into the antecedents, so that, whilst being unable to deny the 
possibility of amentia resulting from such conditions, it can cer- 
tainly be positively affirmed that such instances are exceedingly 
rare. 

An instance which is sometimes quoted in support of the influ- 

* See Dr. Lankester's report, quoted in Newsholme's " Vital Statistics." 



Causation 27 

ence of maternal impressions is the siege of Paris. Legrand du 
Saulle says : " Out of 92 children born in Paris during the great 
siege of 1870-71, 64 had mental and physical anomalies, and the 
remaining 28 were weakly ; 21 were imbecile or idiotic, and 8 
showed moral or emotional insanity." But may it not be that 
these effects were the result of the physical condition of the 
mothers attending this dreadful time — of the environment rather 
than of any mental impression ? 

As showing what little real effect the mother's mental state 
has upon the child, I may here refer to the case of children 
born whilst, or shortly after, the mother was insane. This is 
by no means an uncommon event ; in fact, a certain number of 
children are born every year within lunatic asylums, and I have 
traced the subsequent history of thirty-eight of these up to 
periods at which any mental abnormality would have been 
evident. In fourteen of these women the insanity was of a 
temporary nature, due solely to nervous breakdown at a trying 
period, and morbid heredity was absent. Out of the fourteen 
children, ten were alive and well in body and mind at ages varying 
from three to fifteen years, whilst four were dead. On the other 
hand, in twenty-four women, the attack of insanity was accom- 
panied by a pronounced morbid inheritance. Out of these 
children only three were alive and well, whilst twenty-one had suc- 
cumbed, all, with one exception, a few months after birth. Owing 
to the great difficulty of following up such cases, these figures 
are necessarily small ; but I cannot do other than regard them 
as additional evidence of the slight effect of the mental state 
during gestation, and of the important influence of morbid 
heredity. 

2. Injuries to the Fcetus. — In a few cases amentia is attributed 
to an injury received during intra-uterine existence, but, as these 
in no way differ from those in which injury is inflicted after birth, 
it will be better to consider them with the latter group. 

2. During Birth. 

1. Abnormal Labour. — It is generally considered that this is 
a very important and frequent cause of mental deficiency. Beach 
and Shuttleworth attribute no less than 17-5 per cent, of their 
cases to such cause, of which 14*2 per cent, were due to protracted 



2 8 Mental Deficiency 

labour causing pressure, and 33 per cent, to instrumental delivery. 
It is to be remembered, however, that these statistics were con- 
fined to institution cases, and I believe that such are hardly 
representative of amentia in general. 

Where difficulty in parturition causes mental defect, it is 
because a gross lesion of the brain has been produced ; such 
cases are generally of a severe degree, and consequently tend to 
gravitate to the special institutions. In corroboration of this, 
I found that a history of these factors was much more common 
among the severer grades at Darenth Asylum than amongst the 
patients in the London County asylums ; but even in those at 
Darenth careful inquiries elicited that in the majority pro- 
nounced morbid heredity was also present. Out of 18 per cent. 
of cases in which I obtained a history of abnormal labour, pre- 
cipitate labour occurred in 2 per cent., protracted labour with 
asphyxia in 14 per cent., and instrumental delivery in 2 per 
cent. ; but in only one-ninth of these was there no neuropathic 
predisposition. All of these latter were cases of asphyxia 
neonatorum, and as they are confirmed epileptics, it is probably 
largely owing to the convulsions that the mental arrest is due. 

I am therefore of opinion that the importance of abnormalities 
of labour as a cause of amentia has been much overrated, and 
that the total number of cases which are the immediate con- 
sequence of these conditions is relatively very small, being 
probably not more than 1 or 2 per cent, of all aments. It is true 
that the parents of the patients are generally quite satisfied with 
this explanation ; they find it much more comforting to believe 
that the unfortunate child is the victim of some extraneous 
factor than the product of hereditary taint ; but I am con- 
vinced that, if careful inquiries are made into the family histories 
of these cases, pronounced hereditary tendency will be found in 
a very large proportion. On the other hand, there can be no 
doubt that where such morbid heredity exists, any difficulty 
during labour — and especially if attended with asphyxia — will 
have an important contributory effect ; and it is certainly 
responsible for many of the gross brain lesions, with their re- 
sulting paralyses and convulsions, which are so common in the 
more severe grades. It is to be remarked that abnormal presen- 
tations and anomalies of labour are probably of much greater 



Causation 29 

frequency in psychopathic than in mentally sound women, as 
also with defective than with normal children. 

Little,* in an important paper published in the year 1862, 
was the first in this country to draw attention to mental and 
physical defects resulting from abnormalities of labour. He 
collected a series of 63 cases presenting various defects of this 
kind, the most common cause being asphyxia due to pro- 
tracted delivery ; but he himself says : " It is obvious that the 
great majority of stillborn infants whose lives are saved by the 
attendant accoucheur recover unharmed from that condition " — 
a statement which has since been fully endorsed by many 
eminent obstetricians, and which is confirmed by everyday 
experience. It is indisputable that in a certain small percentage 
of cases in which asphyxia or haemorrhage occurs some degree of 
paralysis results — indeed, this condition is known as " Little's 
disease " — also that of the cases so affected a small number may 
show mental impairment. Out of the 63 cases of lesions col- 
lected by Little, however, there were only 11 in which the 
intellect suffered, 2 of these being actually idiotic, and the 
remaining 9 suffering from various degrees of feeble-minded- 
ness. In all his cases the patients were seen at an age at which 
mental impairment would have been noticed had it existed, and 
in some of those who were physically defective the mental 
capacity is described as being beyond the average. Unfortu- 
nately, Little did not inquire into the family history of his cases, 
but his paper affords no evidence that amentia is at all a common 
result of abnormality of labour. In this connexion it may be 
remarked that it is recorded of Samuel Johnson that " he was 
born almost dead, and did not cry for some time." 

With regard to instrumental delivery, we have only to con- 
sider the number of children who are delivered by forceps every 
day, and the fact that the head of the child is even normally 
subjected to great pressure in the parturient canal, to arrive at 
the conclusion that the proper use of the forceps can play no 
practical part in the production of amentia. It may further be 
remarked that artificial compression of the child's head after- 
birth has been long practised by several races of people, and is 
even now still in use in the Toulouse district of France, without 
* Little, Teansactions of the London Obstetrical Society, 1862. 



30 Mental Deficiency 

any apparent evil effects, and certainly without producing idiocy. 
Dr. Delisle* says that, although in France the practice is slowly 
dying out, it still persists to a surprising extent. He finds, 
however, that it shows no tendency to become hereditarily im- 
pressed upon the race nor is there any sufficient evidence to 
support the belief that it causes either any arrest of physical 
or mental development, or any unusual tendency to insanity. 
Lastly, Spiegelbergf says that " the indentations and depres- 
sions which result in the cranial bones from pressure have a 
comparatively unimportant influence on the children." 

2. Primogeniture. — It is said that first-born children are more 
liable to be mentally defective than are those born subsequently, 
and this is attributed partly to a supposed increased mental 
instability of the mother during a first pregnancy, and partly 
to the undoubted fact that labour is more protracted in pri- 
miparae. But it has already been seen that neither the mother's 
mental state nor protracted labour really have very much 
influence upon the intellectual status of the child in the absence 
of neuropathic predisposition, so that the question of primo- 
geniture as a cause of amentia need hardly be seriously dis- 
cussed. As a matter of fact, I believe the statement that an 
undue proportion of idiots are first-born children is decidedly 
open to question, and my own experience is to the effect that it 
is more common for the later-born, and not the first-born, to be 
affected. In those families in which there is a pronounced 
tendency to mental and physical degeneracy, the effects usually 
appear to be more and more marked upon each successive child, 
and often enough the idiot is actually the last born. I have 
notes of not a few families in which the first one or two children 
presented no great departure from the normal ; these were 
followed by one or two others who succumbed to ordinary 
children's ailments, from which healthy children would probably 
have recovered ; then came the idiot, in some cases to be 
succeeded by a number of still-births. 

3. Premature Birth. — Where hereditary predisposition exists, 
it is probable that the child who is prematurely born will have 

* Delisle, "Artificial Deformity of the Skull," Bull. Soc. d'Anth. de 
Paris, 1902, fas. 2. 

t Spiegelberg, " Text-Book of Midwifery." 



Causation 31 

less chance of attaining complete mental development than will 
the one who goes to full term ; but in the absence of other factors 
I do not believe that premature birth has any effect upon the 
resulting mental condition. 

3. After Birth. 

The factors acting after birth which are capable of producing, 
or assisting in the production of, amentia may be considered 
under the following headings : 

1. Traumatic. 

2. Toxic. 

3. Epileptic and teething convulsions. 

4. Defects of nutrition. 

It may be said at the outset that, although most of these 
conditions may give rise to amentia unaided, the number of cases 
solely and simply due to them is relatively small, and for the 
most part their influence is contributory or exciting only. 

1. Traumatic. — An injury to the child's head in the early 
months of life, or whilst it is still within the uterus, is a frequently 
alleged cause of mental defect ; but in most cases careful inquiry 
will serve to show the extremely trivial nature of the injury 
received, and will make it abundantly clear that it could have 
no connexion with the patient's deficiency. In other cases, 
however, the history — particularly of unconsciousness — leaves 
no room for doubt that a severe trauma has been inflicted, 
and I believe that in a small number of cases this is the direct 
cause of amentia. In such cases it is probable that rupture of 
vessels has taken place, leading to the destruction of a localized 
area of brain tissue, and in most of these patients the amentia 
is accompanied by epilepsy or paralysis. 

2. Toxic. — In a certain proportion of cases of acute infectious 
disease occurring in infancy, such as scarlet fever, enteric, whoop- 
ing-cough, diphtheria, and measles, as well as in otitis and 
rhinitis and acute polio-encephalitis, there are objective signs 
that a cerebral lesion has been produced. Perhaps in some 
of these affections (particularly pertussis) the change may be 
in the vessels of the brain or its meninges ; but in most the 
symptoms rather point to a direct poisoning of the brain cells ; 



32 Mental Deficiency 

accordingly I have grouped them together as " toxic." The 
majority of children so affected die ; others make a complete 
recovery ; whilst in a few others death does not take place, but 
a permanent legacy remains in the form of paralysis, epilepsy, or 
amentia. I shall refer to these cases again in considering the 
question of pathology, but here it may be stated that, although 
toxic processes of this kind may undoubtedly produce amentia, 
the number of such cases is relatively small. In exceptional 
instances the amentia may be caused indirectly through " sense 
deprivation." 

It is probable that the variety of amentia known as " infantile 
cerebral degeneration " or " amaurotic family idiocy " is really 
due to some form of toxin, although the pathogenesis of this 
disease is as yet very obscure. 

Sunstroke is an uncommon cause of mental defect, but I have 
seen three cases in which the closest inquiries failed to reveal 
any other cause, so that I am disposed to think that the exposure 
of a young infant to a very hot sun may occasionally produce a 
cerebral lesion and lead to an arrest of development. In two of 
the cases the exposure occurred in India ; in the third, in this 
country during a very hot summer, and all of them were attended 
with unconsciousness. 

The above are the chief etiological factors responsible for 
the gross cerebral lesions which sometimes lead to amentia. In 
addition, cerebral new growths may occasionally so act. 

3. Epileptic and Infantile Convulsions. — Convulsions of some 
kind or other are amongst the most frequently alleged causes of 
amentia ; but it is easy to mistake effect for cause, and careful 
inquiries show the number of aments so produced to be relatively 
small. 

Severe and frequent epilepsy in the adult often leads to de- 
generation and dementia, and in infancy, whilst the brain is 
still rapidly growing, it may cause imperfect development and 
consequent amentia. But such cases are comparatively in- 
frequent, and in all probability do not comprise more than about 
3 or 4 per cent, of all aments. 

Infantile convulsions, particularly those occurring during den- 
tition, are often assumed to be entirely distinct from epilepsy, 
but in reality there is no clear line of division between the two. 



Causation 33 

In many, perhaps most, cases of infantile convulsions the history 
will show the presence of an hereditary predisposition, and in 
many patients they recur in later life as ordinary idiopathic 
epilepsy. Sir William Gowers states that " a considerable 
number of cases of epilepsy date from infantile convulsions." 
In the presence of morbid heredity, it is often exceedingly 
difficult to say whether convulsions are the cause of the mental 
deficiency, or merely symptomatic of it, but my own experience is 
that true " eclampsic " amentia is a comparatively rare con- 
dition. Some further remarks on the relationship existing 
between convulsions and amentia will be given in subsequent 
chapters. 

4. Malnutrition. — There can be no doubt that the general 
environment, and especially the quantity and quality of the food, 
the amount of fresh air, light, warmth, and the care bestowed 
upon the growing child, have an important influence upon his 
bodily development. This is well shown by a comparison of the 
physique of town and country children. But the same does not 
seem to hold good with regard to mental development. Here 
sensory stimulations seem to be almost as important as food, and 
the intellect of the gamin of the slums is often vastly superior 
to that of the lusty country clodhopper. 

In some instances, as will be seen in treating of mentally 
defective children, an adverse environment gives rise to delayed 
mental development, and the same result may follow serious 
ill-health or disease ; but on the whole it may be said that these 
factors have comparatively little influence in producing amentia 
in the absence of hereditary predisposition. Rickets is some- 
times the accompaniment of mental deficiency, but I doubt 
whether it is ever its cause. One variety of defect, however — 
namely, cretinism — is undoubtedly due to the deprivation of a 
specific nutritive material. 

General Considerations. 

Having seen what are the chief intrinsic and extrinsic factors 
associated with amentia, as well as the extent to which they 
occur, we may now consider the manner in which they act. 

With regard to these two groups, it is clear from the account 

3 



34 Mental Deficiency 

already given that a history of one or other factor of the environ- 
ment (extrinsic) is found in a very considerable proportion of 
cases (65 per cent.) ; and, bearing in mind that evidence of this 
kind is much easier to elicit than is a history of morbid heredity, 
it is not surprising that many writers have attributed great im- 
portance to these external factors. At first sight I was inclined 
to do so myself, and it was only when I found how often pro- 
nounced morbid heredity lay behind that I came to a different 
conclusion. I am far from denying that the environment, even 
when morbid heredity is present, has no effect. Whether the 
fertilized ovum be inherently defective or not, it is evident that 
its development may be interfered with by injury or disease ; 
also that it must be to a considerable extent dependent upon 
the quantity and quality of the nourishment it receives, either 
whilst within or without the uterus. Consequently, a condition 
of actual disease, ill-health, or starvation of the mother cannot 
but be injurious to the growing embryo ; and the same may be 
said of the improper food, impure air, deficient light, and inade- 
quate sleep, which are so often the lot of young children in our 
city slums. What I wish to point out, however, is that, as far 
as my experience goes, injurious external factors of themselves 
but rarely give rise to mental defect, and when they do so it is 
usually because they have produced a gross lesion of the brain. 

The result of my inquiries has been to convince me of the 
immense importance of morbid heredity in the production 
of amentia. It would, of course, be desirable thai these 
statistics should be compared with similar ones regarding the 
mentally normal population. As far as I am aware, none such 
exist, but for several years past I have been gathering details 
from hospital and private patients, and I am fully satisfied that 
the amount of morbid heredity is absolutely insignificant in the 
mentally normal as compared with the defective population. 
Instances of an ancestor dying of consumption, or being addicted 
to drink, or even being epileptic or insane, are not uncommon ; 
but it is decidedly exceptional to find definite and pronounced 
neuropathic heredity in an individual of normal bodily and 
mental development. Conversely, the number of cases of pro- 
nounced mental defect (in which a tolerably complete family 
history is forthcoming) which can be solely attributed to extrinsic 



Causation 35 

or environmental causes is probably not more than 20 per cent, 
at the very outside. 

So much, then, for the relative importance of the two classes 
of factors. Let us now consider the modus operandi of each in 
bringing about arrest of cerebral development. 

1. Intrinsic or Hereditary Influences. 

It would obviously be out of place to enter into any detailed 
account of the various theories regarding heredity, but there are 
some points which have such an important bearing upon the 
causation of amentia that they must be alluded to. Now, it is 
contended by Weismann* that the environment has practically 
no effect upon the germinal plasm, but that this latter is handed 
down unaltered through all the ages, and simply transmits 
qualities or possibilities of development which have existed ab 
initio. Upon this assumption disease and unhealthy surround- 
ings, however much they may affect the individual, are power- 
less to influence posterity, and " degeneracy " is an utter myth. 
I am decidedly of opinion, however, that this theory is contra- 
dicted by the facts of everyday life, and I believe that the 
germinal plasm is capable of modification by the environment, 
and that the alteration so produced may very materially affect 
subsequent generations. 

Weismann's doctrine apparently receives a good deal of sup- 
port irom the statement that " acquired properties are not trans- 
mitted," and there is no doubt that of certain acquirements this 
statement is true. The examples generally adduced are such 
mutilations as the docking of dogs' tails, the nose-slitting of 
savages, systematic compression of the cranium, and, above 
all, the practice of circumcision. It is true that mutilations of 
this kind have been performed systematically upon generation 
after generation, and yet they show no tendency to be trans- 
mitted to the offspring or to impress themselves upon posterity. 
Acquired local properties of this kind, therefore, are certainly 
not transmitted. 

But there is another kind of modification which stands on 
quite a different footing, inasmuch as it is not local, but general 

* Weismann, " The Germ Plasm," and other works. 

3—2 



36 Mental Deficiency 

and universal in its extent. I refer to the effect of certain 
diseases. In some diseases the pathological change is almost as 
localized as are the mutilations just referred to ; but in others 
there is abundant evidence that the whole organism is affected. 
For instance, in such conditions as extensive pulmonary tuber- 
culosis, chronic alcoholism, acute rheumatism, syphilis, diabetes, 
pyaemia, anaemia, and possibly also in some cases of cancer and 
other wasting diseases, it is clear from both clinical and patho- 
logical experience that not a local, but a general, change has been 
produced. Can we imagine that, amid all this disturbance of 
metabolism, the germ and sperm cells remain unaffected, that 
they lead a charmed life, utterly indifferent alike to the effect of 
poison or the quantity and quality of their food ? Assuredly not. 
The germinal plasm, endowed as it is with functions of the utmost 
importance, is yet in its origin but a highly specialized somatic 
tissue. Like other tissues, it is dependent for its growth and 
development upon the blood-supply, and, also like them, it is sus- 
ceptible to the action of poison. Under certain abnormal con- 
ditions its maturation may be delayed, and there are many facts, 
some of which have been cited in previous pages, which con- 
clusively demonstrate that it may be injured by certain bodily 
diseases. 

It is on this point that the experience of the physician is dia- 
metrically opposed to the doctrine of Weismann. One observes 
in medical practice so much difference between the mental and 
bodily vigour of those children who are the offspring of pro- 
nounced alcoholic or phthisical fathers, as compared with 
children of healthy parentage, that it is impossible to avoid 
the conclusion that a serious deterioration of the germinal plasm 
has taken place. Not only the subject of mental deficiency, 
but everyday experience supplies ample evidence of the im- 
portance of morbid heredity upon offspring, and, however much 
the theorist may ignore its influence the physician is unable 
to do so. 

I think, therefore, that it cannot be questioned that the ger- 
minal plasm shares in those alterations of the bodily protoplasm 
which result from disease and environment. According as this is 
favourable or unfavourable, the modification will be progressive 
or retrogressive ; consequently, each individual is a potent influ- 



Causation 37 

ence for good or ill in the development of the race. The environ- 
ment of to-day will become the heredity of to-morrow, and the 
statement that the sins of the fathers are visited upon the children 
unto the third and fourth generation is an undoubted and 
important physiological truth. 

With regard to the causation of amentia, I believe that there 
are certain diseases which bring about a deterioration of the 
germ plasm. The chief of these are alcoholism and consump- 
tion, although it is probable that other poisons, sexual excesses, 
and many factors of modern life, may, by lowering the general 
vitality, produce a similar effect. In consequence, there results 
a pathological change in that part of the offspring which is at 
once the most elaborate, the most vulnerable, and of most 
recent development — namely, the cerebral cortex. This change 
consists in a diminished control of the higher, and increased 
excitability of the lower, centres, and is manifested clinically as 
neurasthenia, hysteria, migraine, and the milder forms of epilepsy. 
We may say that a neuropath has been created. Should the 
adverse environment continue, or should such a person marry one 
similarly tainted, then the nervous instability becomes accentu- 
ated in the following generation, and insanity, the graver forms 
of epilepsy, and early dementia, make their appearance. If the 
process is further continued, the third generation w T ill be charac- 
terized by a tendency to imperfection of anatomical development, 
and there will be a strong probability of one or more children 
suffering from amentia ; should the morbid heredity be accom- 
panied by any injurious factor of the environment (such as those 
we have described), this probability will become a tolerable 
certainty. Degeneracy is here well established, and the well- 
known " stigmata " are usually abundant. Finally, complete 
sterility appears, and the family becomes extinct. For this form 
of amentia due to hereditary influences I have proposed the term 

PRIMARY. 

It is not suggested, of course, that the three grades of mental 
disease above described are necessarily restricted to three suc- 
cessive generations. All the degrees may exist, and frequently 
do, amongst members of one and the same generation. Neither 
do I wish to infer that the neuropathic heritage always cul- 
minates in amentia in the third generation. It may be so 



3S Mental Deficiency 

modified by the admixture of fresh blood that this end may be 
much longer delayed ; it may, indeed, even be eradicated in 
some instances. On the other hand, it occasionally happens 
that idiocy of the grossest type results from the presence of 
alcoholism and consumption in the immediate ancestors without 
any intermediate abnormality of the nervous system having 
been produced. This, however, is exceptional, and I believe 
that the outline given above is, on the whole, a tolerably accurate 
picture of the successive steps in the production of amentia. In 
many of the families of whom I have histories it is actually 
possible to trace this downward march, and further evidence to 
the same effect is afforded by statistics regarding the etiology 
of the other mental affections. For instance, in persons suffer- 
ing from migraine, neurasthenia, and hysteria, it is uncommon 
to find marked ancestral nervous or psychic disturbance, but 
a history of alcoholism and phthisis, as well as of modes of 
living attended with severe nervous stress and strain, is fre- 
quent. In the milder forms of epilepsy morbid neuropathic 
heredity becomes more marked, and in the severer forms of this 
affection it is present, according to Sir William Gowers, in about 
35 per cent, of cases. In persons suffering from insanity the 
morbid heredity rises to 50 or 60 per cent.,* whilst in amentia, 
as we have seen, it is present in 80 per cent, of cases. 

These figures well show the gradual accumulation of morbid 
heredity which lies behind the different grades of mental dis- 
ability, as well as the potency of the hereditary factor in the 
causation of amentia. We may, indeed, say of this latter affec- 
tion that it is the final manifestation of a progressive psycho- 
pathic diathesis. 

As throwing some further light upon amentia from this aspect, 
it may not be out of place to refer to the contemporaries of these 
persons. Whilst inquiring into the causes of amentia, I took the 
trouble to ascertain the number and condition of all the brothers 
and sisters of 150* patients. I divided these into two classes, 
which were designated "satisfactory" and "unsatisfactory." 
The satisfactory group comprised all those who were said to be 
healthy in mind and body, and were able to support themselves. 

* J. S. Bolton, "Amentia and Dementia," Mott's "Archives of 
Neurology," vol. ii. 



Causation 



39 



The unsatisfactory consisted, in addition to those prematurely 
dead, of those who were either mentally affected, or were suffering 
from marked and permanent ill-health, or were leading a life of 
vagabondage or crime. Such details were, of course, difficult 
to get, and as the valuation was generally that of the parents, 
the figures are almost certainly more favourable to the class than 
the real facts. These figures are shown in the following table : 



TABLE VI. 

Showing the Condition of 150 Aments with their Brothers and 

Sisters. 

{In the 150 families there were 1,269 children bom.) 



Unsatisfactory. 


Satisfactory. 


(a) Born dead 

(b) Since died : 

Under 1 year . . 138' 
,, 3 years.. 107 
„ 10 „ .. 37 
,, 20 ,, .. 8 

Over 20 ,, .. 25. 

(c) Mentally affected 

(d) Diseased, paupers, or 

criminals 


170 

-315 

245 
83 


Said by parents to be 
mentally and bodily 
healthy 456 


Total 


813 


Total .. .. 456 




1,269 



Some points in this table are worthy of note. Firstly, the large 
number of children born. According to the Fortieth Annual 
Report of the Registrar-General (1876), the average number of 
births to a marriage in England and Wales is 4*63. The number 
of children in 150 normal families would therefore be 694 ; 
whereas in the families we are now considering the number born 
alive is 1,099, or an average of y^ per family. Secondly, the 
large number of still-births. No precise data exist with regard 
to the number of these in the normal population, as they are 



40 Mental Deficiency 

unregistered, but Farr and Newsholme estimate them at about 
4 per cent, of the total births. If these families were normal, we 
should therefore expect to have 44 children stillborn, whereas 
we find 170. Thirdly, the mortality of these children is even 
more remarkable. According to the life table of the Registrar- 
General, based upon the years 1881-1890 (Supplement to Fifty- 
fifth Annual Report, 1895), 

Had the 1,099 Children belonged to the "Average " Whereas there were 

Class, there would have been surviving — surviving — 

At end of 1 year . . 937 . . . . . . 961 

3 years . . 864 . . . . . . 854 

10 .. 823 .. .. .. 817 

„ 20 . . 800 . . . . . . 809 

In other words, the mortality is practically identical with the 
normal. 

I do not wish to press the point unduly, because the number 
dealt with is but small. Statistics of this kind are exceedingly 
difficult to obtain, and I know of no others at present existing ; 
but if further observations should confirm these here given, it 
would follow that, although the progeny of neuropaths are 
greatly in excess of those born of the average population, there 
is, as a whole, no corresponding excess of mortality ; and this 
in spite of the fact that, as we shall presently see, the expectation 
of life of those who are actually mentally deficient is sub- 
normal. Even assuming that the 456 brothers and sisters of 
these aments are really sound in body and mind, as stated by 
their parents (which, however, I greatly doubt), it is to be re- 
membered that they come of a pronounced morbid stock, and 
are not only capable of, but exceedingly likely to, transmit the 
taint to a subsequent generation. In fact, it is in regard to these 
rather than the actual aments, that the greatest danger of 
propagation lies. 

The following family history charts afford graphic illustrations 
of many of the points referred to. 

In them amentia, insanity, or epilepsy, is shown as • ; 
alcoholism, tuberculosis, general ill-health, neuroses, and prema- 
ture death, as % ; whilst persons presumably healthy, dying 
from natural causes, or of whom no information is obtainable, 
are shown as O. 



Causation 



4i 



CHART I. 

SHOWING GOOD HEREDITY CONTAMINATED BY SLIGHT 
ALCOHOLIC HEREDITY AND TOWN LIFE. 



Country , 



TorM 







Alt sai d (.ode healthy 



1 — 1 — 1 — 1 — 1 1 r 

\l J5 J? if M Jl 

• o ® o • §> 

Died22 " ^ ' nicct35 feeble 

Consumption g Consumption Minded 



^ 


f- 


^ 


/fisca^rroyes^^ 




SL1 


<2 










4' 


v| 







Case No. 131, IF. /. G. 



CHART II. 

SHOWING GOOD HEREDITY CONTAMINATED BY MORBID 
HEREDITY. 




Health, StUticrn ^ /feailh, ^ SizU^nn \ S>ciUiorr, 



V 






C^se No. 10, ^4. C. 



4 2 



Mental Deficiency 



CHART III. 

SHOWING GOOD HEREDITY CONTAMINATED BY INSANE 
HEREDITY. 










/Vo tnform afc on 



I . - 



/^ e&?Z~M''cSe d . 



/IU AtUvIr f/ieadCSiy 



X \t M J£ J£ J*L 1l 






^yo-ncy 






Case No. 5, /. W. J. 



CHART IV. 

SHOWING THE EFFECT OF INSANE + PHTHISICAL HEREDITY 



deed en 



Cactus unj-szoyy/z. 






Consum/Won SrcwcSitd^s 



Vtedyt / oral . 

&rey/its 
£>tsease 



15 



J 






i 



£ 



/dtot Said /deaf. Sacd /Ye-sc 

toie to6e 

ZieaUihy A e at My 



Case No. 99, F. W. 



Causation 



43 



CHART V. 

SHOWING EFFECT OF ALCOHOLIC AND INSANE INHERITANCE 
+ PHTHISICAL INHERITANCE. 



WMcohoU 
w £>ied en 




66666606 






Case No. 174, C. B. 
CHART VI. 

SHOWING THE EFFECT OF DOUBLE MORBID HEREDITY. 



* •-rft 



Z)ceo£ of< 



sumftfc 



&«<?*"£%% 






y*s~o/77 ^ eu 'S lX ^f 1 



¥^ 









if \$ Jg J? IS 9 Y?]? \*- i^ 5 k* i* 5 " Is* 

66g • o # o • • p 06 • 




H 



i*0i 



ft. 









Xase No. 9, 5. V. 



44 



Mental Deficiency 



CHART VII. 

SHOWING THE EFFECT OF DOUBLE MORBID HEREDITY. 



Died in Cfiildfiooc* ^" s 




"f"*" Sndecclt 



•Jo* >v 



? — ' Alu/e -* 
\P. 



.Jtfcleact.. 



5 5 






Case No. 83, W. A. M. 






CHART VIII. 

SHOWING THE EFFECT OF A DOUBLE INSANE INHERITANCE 

+ SYPHILIS. 




co? to&eAea-ZlAy JVeurotic 



Jhk 



sum 

ItAy 

1 



I h 11 Si *t * 1 



9 S 



PW 



Cas* Afo. 97, P. W. 



Causation 



45 



CHART IX. 

SHOWING THE EFFECT OF CONSANGUINITY WITH A TENDENCY 
TO VASCULAR LESIONS OF THE BRAIN. 




£USU 



•s Con sumzjz fo 

//ad deftm 
4sy/um seffraL 



£>teo/ <?6 



bbibhik 



^ ^ ^ ^ »S 






7ie: 



Case No. 70, F. E. V. 



We must now refer to another type of case which at first sight 
appears to be quite distinct from the one just described, inas- 
much as the patient may be the only one of the family showing 
any sign of deterioration, his brothers and sisters being well 
developed in body and mind. Similar hereditary influences 
exist here also, though not in such marked degree, and it is in 
these cases that they are mostly present on one side only. 
Evidently in these instances, however, the condition cannot be 
attributed entirely to defects in the germinal plasm, as in that 
case other members of the family would also show signs of 
defective development ; the question therefore arises as to why 
one alone should be affected. 

It is under these circumstances that I believe the condition of 
the mother during gestation to be of most vital importance to the 
child ; obviously it is a difficult matter always to obtain precise 
and accurate information on this point, but I have been much 
struck by the fact that it is just in these — what one might call 
sporadic — cases of idiocy that nearly all the instances of abnormal 
condition of the mother during pregnancy have occurred. These 



46 Mental Deficiency 

conditions have already been discussed, and it will be sufficient 
to note here that the one most frequently associated with the 
birth of an anient is a state of general ill-health and exhaustion, 
in the poorer classes often accompanied by a deficiency of proper 
food. In several cases it has happened that during this time 
the father was out of work. 

Apparently, under these less-pronounced conditions of here- 
ditary predisposition, the germ plasm, although to a certain 
extent vitiated, is still capable of proceeding to the perfect 
structural development of the embryo, provided no untoward 
circumstances intervene to further embarrass its growth ; but 
should there happen at this time any deterioration in the health 
of the mother, whereby the blood supplying the rapidly growing 
ovum is considerably modified in its nutritive qualities, then 
incomplete development is very likely to happen. As far as 
my experience goes, the physical condition of the mother is of 
far more importance than her mental state, except in the cases 
in which this may modify the physical condition. 

In other instances the same result is attained by a somewhat 
different contributing or, as it may be termed, exciting factor. 
One fairly common such is premature birth ; if by any unfortu- 
nate chance this should happen where there are already present 
p edisposing factors, even if slight, the child is extremely likely 
to show some mental deterioration as compared with his brothers 
and sisters. In other cases prolonged labour, attended with 
more or less asphyxia, may act in the same manner ; the tem- 
porary obstruction of the cerebral circulation need not be 
enough to give rise to any actual lesion, or in a healthy child 
to produce any damage whatever, but in the present instance 
it is all that is required to interfere with the perfect development 
of the nerve cells, and some degree of weakmindedness is the 
result. 

In the same way act some of the factors occurring after birth, 
such as trauma, convulsions, rickets, infectious fevers, men- 
ingitis, etc. It has already been seen that in the larger proportion 
of these cases ancestral defects are present, and the exciting 
factor probably acts by causing a derangement of the cerebral 
circulation or metabolism from which the nerve cells are unable 
to recover. 



Causation 47 

It is necessary to bear in mind that in the majority of cases 
of amentia factors such as the above are only accessory, and that 
the real origin of the condition lies in the defect of the germinal 
plasm, the result of morbid heredity. 

The term developmental was applied to such cases by Langdon 
Down, but in view of their inherent defect it might be preferable 
to refer to them as instances of delayed primary amentia. 



2. Extrinsic or Environmental Causes. 

It has been seen that, although adverse conditions of the 
environment are present in a considerable number of cases of 
amentia, the proportion in which they are the direct and sole 
cause is relatively small — probably at the most not more than 
15 to 20 per cent. To this extent, however, the environment 
does seem capable of producing amentia, although in many in- 
stances this is but the incidental phase of a process which is really 
degenerative and of which the end is dementia. As such cases 
are entirely independent of morbid heredity and of any inherent 
defects of the germinal plasm, I have proposed to call this variety 
secondary amentia. I have already enumerated these factors, 
and since many of them are pathological processes which result 
in a gross lesion of the brain, it will be more convenient to 
describe the manner of their action together with their clinical 
characteristics. A few, however, give rise to a general arrest 
of development without any naked-eye lesion, and these may 
briefly be referred to in this place. 

Under normal conditions the brain of the child grows with 
extreme rapidity during the first few years of life. This is in 
consequence of its inherent capacity for growth plus the stimula- 
tion of sensory impressions and the presence of an adequate 
quantity and quality of blood. This inherent capacity may be 
normal, but the necessary stimulation or food so deficient that 
the gradual unfolding of the mental faculties does not take 
place, or takes place so tardily that some degree of backwardness 
is the result. Cases of this kind, in which development is 
delayed, are extremely common, and it usually happens that 
upon the removal of the cause mental expansion rapidly ensues. 
Should the adverse conditions continue sufficiently long, however, 



48 Mental Deficiency 

the brain cells seem in some cases unable to recover ; the mind 
never makes up the lost ground, and some degree of mental 
deficiency is the result. In my experience actual idiocy is never 
caused in this way, and the resulting defect is of comparatively 
mild degree only ; it is nevertheless a true amentia. I do not 
think that cases of this kind are very common, but they form a 
certain percentage of the adult feeble-minded and of mentally 
defective school-children, particularly in the large towns. The 
cause seems usually to be that combination of factors — drink, 
dirt, and depravity — which go to make up slum life in its worst 
form. 

With regard to the influence of slum life and all its associated 
conditions in producing amentia, it is necessary to sound a note 
of warning. It does happen sometimes that the real mental 
defectives of our large towns hail from the slums, although I do 
not think such is disproportionately the case. Still, a sufficient 
number of defective children come from such areas to make the 
superficial inquirer, content with that which is apparent, jump 
to the conclusion that the pernicious environment is therefore 
the cause of their defect. My own inquiries have convinced me 
that in the great majority of these slum cases there is pronounced 
morbid heredity, and that their environment is not the cause, 
but the result, of that heredity. The neuropath is one who is 
at an economic disadvantage in the struggle for existence. He 
frequently finds it difficult to hold his place, and he is often 
possessed of careless, improvident, and intemperate propensities, 
which cause him to fritter away the money he does earn. He is 
on the down grade. No wonder, then, that he drifts to the 
slums. 

Factors of Causation in Regard to Local Variations of 
Incidence. 

Before concluding this account of causation, it is necessary to 
refer to the connexion existing between certain etiological factors 
and local variations in the prevalence of amentia. 

We have already seen (Chapter II.) that the incidence of 
amentia is not uniform throughout the country, but that in some 
localities it is relatively much higher, and in others much lower, 
than the mean average. Into the cause of this inequality I do 



Causation 49 

not propose to enter, for it is but part of a similar variation in the 
incidence of mental disease in general, and is therefore beyond 
the scope of our subject. But there are certain variations in the 
incidence of amentia relative to other forms of mental disease, 
and in the incidence of the degrees of amentia relative to one 
another, which are so closely connected with the question of 
causation that they must be referred to. 

The Incidence of Amentia relative to Insanity. — The statistics 
of the Royal Commission show that, broadly speaking, 
insanity is more characteristic of the urban and industrial, and 
amentia of the rural, populations of this country. We have 
already seen that the causes of these two conditions are identical 
in kind — namely, morbid neuropathic heredity — but that they 
differ in degree, inasmuch as the heredity is usually more pro- 
nounced in amentia than in insanity. Now, the towns have been 
built up and are being steadily increased by the immigration of 
persons from the country, and it is justifiable to conclude that 
the persons so migrating will possess the qualities of initiative, 
enterprise, and mental vigour in a higher degree than those who 
are content to remain upon the land — that, in short, a compara- 
tively smaller proportion of them will come of a pronounced 
neuropathic stock. This process inevitably tends to the accumu- 
lation in the rural districts of those most saturated with morbid 
heredity — a state of affairs which is often accentuated by 
intermarrying, and so the conditions in these areas become 
more and more favourable to the production of actual mental 
defect. On the other hand, in our towns and densely packed 
industrial centres competition is keen, the stresses and strains of 
life are severe, alcoholism is rife, consumption is very prevalent, 
narrow streets are densely packed with overcrowded houses, 
women advanced in pregnancy continue to work in the mills 
and factories, infants who should be at the breast are reared 
artificially, and, in short, all the conditions are present to pro- 
duce an instability of the higher parts of the nervous system — 
the precursor of insanity. This, in subsequent generations, 
leads to actual defect of structure and consequent amentia, but 
the constant immigration drags fresh blood into the vortex, and 
tends to make insanity rather than amentia the prevailing 
type of mental abnormality. 

4 



50 Mental Deficiency 

The Relative Incidence of the Different Degrees of Amentia. 

— As has been shown in Chapter II., not only is amentia 
absolutely more prevalent in rural than in urban districts, 
but the grosser degrees of defect are relatively in excess also ; 
whilst in the towns mentally defective children are relatively 
and absolutely more prevalent than in the country. I am of 
opinion that there are threo chief factors of town life which tend 
to bring about this result — namely (i) a lessened production, 

(2) an increased destruction of the more severe grades of defect, 
and (3) the presence in the towns of cases of delayed development 
which simulate mental defect, and so cause an apparent increase 
of mild deficiency. 

(1) Lessened Production of Severe Defect : This is due to the 
same causes which bring about a diminished incidence of amentia 
generally — namely, a lessened neuropathic heredity in the town 
dwellers. (2) Increased Destruction of Severe Defect : I am 
unable to give any statistical proof of this, but I think it is pos- 
sible that the relatively higher infantile mortality of the towns 
may be not without effect in causing a diminution of the worst 
grades of defect in these situations, since the mortality of aments 
would seem to be directly proportionate to the degree of defect. 

(3) It has already been remarked that a small proportion of cases 
of secondary amentia are the result of a faulty environment, 
and this I believe to be more prevalent in town than country. 
As we shall see, however, in considering mentally defective chil- 
dren, there is a condition of delayed development w T hich is very 
much more common in densely congested areas, and which 
simulates real amentia very closely. I believe this is responsible 
in no slight degree for the apparent increase of the juvenile 
feeble-minded in towns. In corroboration of this is the fact that 
in the towns there is no relative increase of the adult feeble- 
minded, even when it is remembered that a small proportion of 
those actually born in the towns are gradually squeezed further 
afield in the struggle for existence. 



CHAPTER IV 

PATHOLOGY 

Before discussing the pathology of amentia, it will be an ad- 
vantage to allude to the salient features in the development of 
the cells of the cerebral cortex. 

Development of the Normal Brain. 

The first indication of the brain is seen very shortly after 
fertilization of the germ cell, and consists in an expansion of the 
anterior end of the rudimentary spinal cord to form four primary 
cerebral vesicles. It is by a series of elaborate infoldings of 
these vesicles, and by the multiplication around them of the 
cells composing their walls, that cerebral development takes 
place. By the time the embryo . is six months old the brain 
has assumed the general shape of the adult, although there is 
as yet a complete absence of all those secondary fissures and 
convolutions which are such a characteristic feature of the fully 
developed organ. 

At birth many of these convolutions are present, and the 
brain weighs* from 280 to 330 grammes. During the first six 
months of life growth is exceedingly rapid, the weight of the 
brain at the end of this time being more than double what it 
was at birth — namely, from 600 to 680 grammes. By the end 
of the first year the weight has reached about 750 grammes, 
and from this onward it still continues to grow until the age of 
twelve or fourteen years, when its average weight is 1,150 
grammes in the female and 1,300 grammes in the male. A 
further slight increase takes place during the next seven years, 

* According to R. Boyd, Phil. Trans., i860. 

51 4—2 



52 Mental Deficiency 

and at the age of twenty-one the brain has attained the weight 
of 1,244 grammes in the female and 1,374 grammes in the male. 
From this period growth is very slow, until, according to Broca 
and Peacock, the maximum average weight of 1,269 grammes 
(45 ounces) in the female and 1,421 grammes (50 ounces) in the 
male is attained between twenty-five and thirty-five years of age. 

The progressive increase in size and w r eight is due, firstly, to 
the rapid multiplication, and secondly, to the individual, 
development, of the nerve cells. These arise from the cells lining 
the floor of the primitive cerebral vesicles, and at first they are 
of one uniform indifferent type. Subsequently, however, differen- 
tiation occurs, and features appear which are characteristic, and 
which persist throughout life. It is as a result of this differentia- 
tion that the brain cortex acquires its peculiar laminated ap- 
pearance. Coincident with lamination delicate protoplasmic 
processes arise from these nerve cells, and, pursuing definite direc- 
tions throughout the cerebral mass, constitute the association and 
projection systems of fibres. The former serve to link together in 
the most complicated manner all parts of the brain ; they also 
compose the great association centres of Flechsig ; the latter are 
the pathways by which the brain is connected with the various 
parts of the body. 

Development does not proceed simultaneously in all parts of 
the brain. The nerve cells of certain areas reach maturity much 
earlier than do those elsewhere, and the frontal and parietal 
regions, which there is good reason for thinking are those most 
concerned with the highest intellectual functions, are the last to 
acquire their mature characteristics. In the frontal lobes of the 
seven-months embryo lamination has not yet appeared, and 
the cells are of a uniform undifferentiated type (neuroblasts). 
These are small round cells with a close and readily stainable 
reticulum, but quite devoid of processes, and they lie embedded 
in a matrix which, in the hardened and stained section, some- 
what resembles the grain of marble. In the eight-months 
embryo the neuroblasts are somewhat larger, the reticulum is 
less close and has less affinity for stain, but there are as yet no 
definite processes. At this age it is possible to make out the 
beginning of lamination in this region of the cortex. In the child 
of two weeks old (extra-uterine) the cells have made a consider- 



Pathology 53 

able advance, and they are now readily recognizable as nerve 
cells. A cell body is present, although the protoplasm of this 
differs greatly from the mature cell, being very vacuolated, and 
liable to break away from the nucleus. At this age also the 
cells of the pyramidal layer possess an apical process, and occa- 
sionally other processes are present ; but the apical one is always 
the best developed, and appears to be the first formed. Finally, 
a few years after birth the cell has assumed its mature character, 
and possesses axons, dendrons, and gemmules. In other regions 
of the brain development takes place earlier, and in the motor 
area of the eight-months embryo medium-sized pyramidal and 
also Betz' cells are readily recognizable. 

The processes of the fully developed nerve cells communi- 
cate with one another (physiologically, if not anatomically) in 
an exceedingly complicated network, forming the bands and 
systems of association fibres already mentioned. It is by 
means of them that nervous impulses travel to and from 
all parts of the cerebro-spinal system, and it has even been 
suggested that the nerve cell is of secondary importance, and 
only serves the purposes of nutrition. However this may be, 
there is a definite relation between the appearance of the cell 
as seen under the microscope and the state of the fibre, and 
the condition of the cells forms a convenient and reliable index 
of the presence of disease. 

There can be no doubt that the number and complexity of the 
cell processes, particularly those forming the association systems, 
are intimately connected with the degree and complexity of cere- 
bral activity, and it is highly probable that the intellectual expan- 
sion which takes place after puberty is due to their numerical 
increase and the elaboration of their connexions. It has, indeed, 
been shown by Kaes* that a progressive increase in these fibres 
can be demonstrated up to the middle period of life, after which 
he states that growth ceases and a gradual diminution takes 
place. 

Finally, to complete this brief resume, it may be said that 
the nerve cells and fibres are imbedded in a network of supporting 
tissue (neuroglia cells and their processes), encased in a series 
of delicate connective-tissue membranes — the meninges — and 

* Kaes, Monatsschrift -fur Psychiatrie unci Nenrolgie, 1897. 



54 Mental Deficiency 

the whole organ permeated by a dense ramification of blood- 
vessels. 

Whatever may be the relation of mind to brain, it is now 
fully recognized that the manifestation of mental activity is 
indissolubly connected with the cells of the cerebral cortex. 
Mind develops pari passu with their growth, and fails with 
their decay. Dementia is coincident with their degeneration 
and death, and, as will presently be shown, amentia is associated 
with their incomplete development. 

It is apparent from this outline of cerebral development 
that the period of greatest growth is that between the first 
appearance of the primitive brain and the end of the sixth 
month of extra-uterine life ; consequently, it is during this 
period that the demands upon the environment are greatest, 
and that any adverse factor will be most severely felt. This 
entirely accords with the general experience that, where secondary 
amentia occurs, it is the result of an adverse environment during 
the early months of life. The mental development which takes 
place after puberty appears to be the result of the elaboration 
of association systems, and although, theoretically, developmental 
arrest might occur at this time, such would but rarely be likely 
to result in any pronounced deficiency. On the other hand, in 
cases of primary amentia, the condition is rather one of a general 
inability to develop than of an arrest of development, and the 
cause is in existence anterior to the very beginning of embryonic 
existence. 

THE PATHOLOGY OF AMENTIA. 

Many mistaken notions still exist with regard to the patho- 
logy of amentia. As we shall presently see, in a very con- 
siderable number of these patients, particularly the lower grades, 
there exist gross abnormalities of brain structure, or severe and 
extensive morbid conditions, which are visible to the naked eye. 
Accordingly, it was not unnatural that the earlier observers, 
examining isolated cases in the days when much less was known 
about the structure of the nervous system than is the case at *' 
present, should conclude that in these various anomalies they 
saw the fons et origo of the mental defect. As a consequence, 
amentia was variously attributed to the presence of porencephaly, 



Pathology 55 

hemiatrophy, microgyria, and the like. These views cannot be 
held to-day. In the first place, it has been abundantly shown 
that such conditions may exist without any mental defect or 
deterioration whatever ; whilst, secondly, an increased knowledge 
of the structure of the nervous system, and particularly of the 
nerve cell, together with a greatly improved technique, has 
clearly demonstrated the existence of important cellular changes 
in amentia. 

In support of the statement that these gross conditions cannot 
really be the cause of mental defect, the following observations 
may be cited : About thirty cases have been recorded of absence 
or deficiency of the corpus callosum, most of them in idiots, yet 
Nobiling-Jolly, Eichler, and Klob have each recorded a similar 
case in which there was no mental peculiarity. Likewise with 
another frequent accompaniment of amentia — porencephaly. 
Several cases have been described in which a large cavity existed 
in one hemisphere, and yet there was little or no appreciable 
mental change. Schroeder van der Kolk* mentions a number 
of instances tending to show that a large proportion of one hemi- 
sphere may be diseased, and yet the patient show no mental 
impairment. Finally, with regard to another condition — hydro- 
cephalus — Freud f states it to be an undoubted fact that severe 
hydrocephalus may exist without any paralytic symptoms ; 
whilst ZieglerJ states that such malformations, or even still 
greater defects, may exist in the brain, though during life there 
was nothing whatever to indicate their presence. 

We cannot but conclude, therefore, that although these gross 
changes are frequently associated with amentia, they are not 
essential to that condition, and in discussing the question of 
pathogenesis we must be careful clearly to distinguish between 
what is essential and what is only accidental. 

At the same time it is undeniable that gross malformations 
and coarse lesions are much commoner in the epileptic and 
mentally defective than in normal persons, and it is easy to 
understand, from the description which has been given of the 
causation and hereditary predisposition of these persons, that 

* Schroeder van der Kolk, Sydenham Society Transactions, 1861. 
t Freud, " Infantile Cerebral Lahmung," Wien, 1897. 
X Ziegler, " Text-Book of Special Pathology," 1896. 



56 Mental Deficiency 



such should be the case. On the other hand, there is no doubt 
that certain morbid processes may, even in the previously healthy 
brain, produce such an arrest of neuronic development as to 
bring about amentia. 

The essential basis of amentia is an imperfect or arrested 
development of the cerebral neurones, a fact which is now 
established beyond doubt by careful microscopical examina- 
tions conducted by numerous competent observers. This morbid 
state of the neurones is brought about by the causes which have 
already been described in Chapter II. Accordingly, I shall first 
of all describe these histological changes, relegating the various 
gross anomalies and diseased conditions to a second place. 

The Histology of Primary Amentia. 

Nerve Cells of the Brain Cortex. — As compared with the nerve 
cells of the healthy brain, those of the ament are characterized 
by the following conditions : (1) Numerical deficiency ; (2) ir- 
regular arrangement ; (3) imperfect development of individual 
cells ; and on the whole it may be stated that the amount of 
change discoverable by the microscope is directly proportionate 
to the degree of mental deficiency present during life. 

1. Numerical Deficiency. — Although an actual enumeration 
of the nerve cells present in these cases cannot be made, I am 
convinced, from the careful examination of a large number of 
sections, that the cells composing the grey matter of the cerebral 
cortex are decidedly fewer than in the normal brain. In 
many cases this paucity of cells produces a decrease in the 
thickness of the cortical grey matter which is obvious to the 
naked eye (see Fig. 9, p. 63. Further, although the cells of all 
the layers are fewer than normal, it is the small and medium- 
sized pyramids which are most diminished in number. Ham- 
marberg, as the result of a most elaborate and careful series 
of observations, arrived at a similar conclusion. 

2. Irregular Arrangement. — Hammarberg* states that the 
arrangement of the cortical cells in amentia does not differ from 
the normal ; but my own experience, as also that of several other 

* Hammarberg, " Studien iiber Klinik und Pathologie der Idiotie," 
Upsala, 1895. 



Pathology 57 



observers, is to tne effect that an irregular and haphazard 
arrangement is very characteristic of this condition. The pyra- 
midal cells show the most change, although this, of course, may 
be simply due to the fact that the form of these cells renders 
any irregularity more apparent. Throughout the brain there 
are in this layer numbers of cells lying horizontally, obliquely, 
or completely upside down, even where there is no accompanying 
sclerosis, and where sclerosis is present the irregularity is often 
extreme. 

3. Imperfect Development. — As early as 1879 Bevan Lewis* 
drew attention to the presence, in certain forms of amentia, of 
incompletely developed nerve cells, and similar cells were present 
in cases which I examined. When stained by Nissl's method 
they have the following characteristics : The nucleus is large and 
ovoid in shape ; the nuclear membrane and intra-nuclear network 
are very distinct. The nucleolus is often eccentric, so that in 
some sections it cannot be seen. The cell outline is distinct, 
but, instead of being pyramidal, it is globular or pyriform in 
shape, and angles are completely wanting. The processes of the 
cell are exceedingly few, and in many instances one only can be 
seen (see Plate I., Fig. 4). This paucity of dendrons and also 
of gemmules is still more evident in sections stained by the silver 
method. 

I think it cannot be doubted that the conditions here described 
are due to incomplete development. I have never seen such 
cells in any human brain other than that of an ament ; it is, how- 
ever, interesting to note that, according to Bevan Lewis, similar 
cells exist normally in the second and third layers of the cerebral 
cortex of the ape. Bevan Lewis was only able to discover these 
immature cells in cases of amentia complicated by epilepsy, 
and he thought they did not occur in pure amentia ; but I have 
seen them in cases in which epilepsy was absent. 

In addition to the above, the cerebral cortex of the pronounced 
ament nearly always contains a large number of other cells whose 
development is even less complete, and which closely resemble 
the undifferentiated neuroblasts already described as composing 
the normal frontal cortex up to the eighth month of embryonic 

* Bevan Lewis, " Text-Book of Mental Diseases," 1899 ; also Brain, 
October, 1879. 



58 Mental Deficiency 

existence. In these there is practically no cell body, or at most 
a few irregular protoplasmic strands ; the nucleus is large and 
globular, the intra-nuclear network very distinct, and often dis- 
posed as several fine lines which divide the nucleus into com- 
partments. In fact, they are undifferentiated and undeveloped 
neuroblasts, and in areas of localized agenesis — such, for instance, 
as are seen in microgyria — there is often no other kind of cell to 
be seen (see Plate I., Fig. 1). 

There is another condition of the cortical cells which is exceed- 
ingly common in these cases — namely, pigmentation. This does 
not occur in the immature cells above described, and is chiefly 
seen in the deeper pyramidal layer, in which it is often a very 
marked feature. The pigment is generally situated at one angle 
of the cell, away from the nucleus, but at times it is so abundant 
as almost completely to fill the cell (see Plate I., Fig. 7). It is 
yellow in colour in Nissl or polychrome sections, but appears 
dark brown or almost black in those stained with Marchi's fluid, 
and hence gives to these sections a most striking appearance. 
In several of my cases it was particularly pronounced in the cells 
of the hippocampus (see Plate I., Fig. 8). The exact nature and 
significance of this pigment is unknown, though the reaction with 
Marchi's fluid would suggest that it was of a fatty nature. A 
similar pigmentation, but to nothing like the same extent, is 
frequently found in the central nervous system of patients who 
have suffered from chronic nervous disease (e.g., disseminated 
sclerosis, amyotrophic lateral sclerosis, progressive muscular 
atrophy, chronic insanity, etc.). Its occurrence in these condi- 
tions as well as in aments would suggest that it is an indication 
of defective metabolism, in which the anabolic processes cannot 
keep pace with the katabolic. The pigment is nearly always 
associated with a diminution in the number and size of the Nissl 
bodies. 

Nerve Fibres of the Brain Cortex. — The bands of tangentially 
coursing fibres comprising the association systems show a 
very definite diminution in cases of severe amentia, so great, 
indeed, as often to be apparent to the naked eye. Gene- 
rally speaking, the most marked alteration occurs in the 
fibres composing the outer line of Baillarger, next in the 
super- and inter-radial bundles, whilst the superficial tangential 



Pathology 59 

fibres are somewhat less affected (see Fig. 9, p. 63). The regions 
of the brain most involved are the frontal and parietal lobes ; in 
the motor areas the change is comparatively slight, and in the 
occipital lobes there is often little observable diminution. 

The Neuroglia. — Sclerosis, or overgrowth of neuroglia, occurs 
in some form or other in a considerable proportion of cases. 
Dr. Wilmarth* found it in no less than one quarter of the hundred 
brains he examined. The cause of this condition cannot always 
be determined ; in some cases it would appear to be a develop- 
mental anomaly, and to take place in consequence of the dimin- 
ished multiplication and development of the higher elements — 
the nerve cells. In such cases it is probably of a diffuse nature. 
In a brain of this kind which I examined from an idiot dying at 
the age of twenty years, the whole organ was small, 896 grammes 
in weight, and exceedingly firm — in fact, almost cartilaginous 
in texture throughout. There were no localized patches, but 
microscopical examination showed the presence of a dense 
overgrowth of neuroglia diffused throughout all parts of the 
brain, including the basal ganglia and cerebellum. This in- 
volved the white as well as the grey matter, and was accom- 
panied by a marked numerical diminution as well as irregular 
and incomplete development of the nerve cells and their processes. 
There were no signs of recent degeneration, but the pia-arachnoid 
membrane was somewhat thickened in places. The patient had 
always been helpless and unable to do anything for herself, but 
no definite paralysis was noticeable. She was subject to constant 
choreiform movements, but there were no convulsions. 

In the majority of cases, however, the overgrowth of neuroglia 
occurs in the form of localized patches. These are found 
in three chief situations, although all may be involved in 
a single case. The commonest site is the grey matter of the 
cerebral cortex, which may be occupied by a large number of 
sharply circumscribed sclerotic areas varying in size from a pin- 
head to a hazel-nut, or even larger. As generally seen, these are 
pale firm masses which project above the level of the affected 
hemisphere, they are often marked by a central umbilication, 
and the investing pia. membrane strips from them with unusual 

* A. W. Wilmarth, "Report on the Examination of One Hundred 
Brains of Feeble-Minded Children," Alienist and Neurologist, October, 1890. 



60 Mental Deficiency 

readiness and without causing decortication. This condition 
was first described by Bourneville,* but many examples have 
since been recorded under the name of hypertrophic, nodular, 
or tuberous sclerosis or gliosis. The majority of the patients 
have been markedly mentally deficient and have suffered from 
epileptic convulsions. The patches consist of a dense interlace- 
ment of neuroglia fibres with a varying proportion of cells 
(probably dependent upon their age), and the lamination of the 
adjoining grey matter is often considerably distorted. The 
next most common site is the floor of the lateral ventricles, which 
may be studded with a number of protuberances the size of small 
peas. Microscopical examination shows these to consist of 
almost pure glia tissue, the fibres of which are usually arranged 
in whorls around the centre of the nodule. Finally, a dense 
band of fibrous neuroglia is occasionally seen immediately 
under the pia upon the surface of the hemisphere, closely applied 
to the cortex like a cap. 

When neuroglial overgrowth is present to any considerable 
extent, it produces a marked increase in the weight and consist- 
ence, and often in the size, of the brain. With the lapse of 
time it tends to contract, and the relative age of the cortical 
protuberances may be gauged by the size and depth of their central 
umbilication. It is probably an early stage of extensive neuro- 
gliosis which gives rise to the cranial enlargement in the hyper- 
trophic form of amentia, and this condition is not infrequently 
called " hypertrophy of the brain." The hypertrophy, however, 
concerns the supporting, and not the true nervous tissue. 

Regarding the manner of production of localized sclerosis there 
is much diversity of opinion, although the lesions suggest some 
kind of vascular causation. Jendrassik and Marie point out that 
the first histological change always takes place around the small 
cortical arteries, and in a case of Freud's a sclerotic patch was 
considered to be undoubtedly the result of an embolus of a branch 
of the middle cerebral artery. Striimpell sees in it a possible 
after-effect of his polio-encephalitis acuta infantum. Moreover, 

* Bourneville, " Recherches sur l'ldiotie," etc., Paris, 1893 '> see a ^ s0 
Joseph Sailer, " Hypertrophic Nodular Gliosis," Journal of Nervous and 
Mental Disease, 1898, p. 402, in which an account is given of previously 
recorded cases ; also Freud, " Infantile Cerebral Lahmung," p. 136. 



Pathology 6 1 

the view of vascular origin derives considerable support from 
the fact that in some cases the lesions are strictly confined to 
one hemisphere. It is therefore not improbable that a consider- 
able number, at all events, of these cases of tuberous sclerosis 
have their origin in one or other of the vascular cerebral lesions 
occurring before birth or in early infancy, in some cases being 
caused by occlusions, in others by the dissemination of a poison. 
But such a result is by no means invariable in these cases, and as 
to why the result should in some be sclerosis, in others soften- 
ing with cystic formation, or in others chronic meningo-encephal- 
itis with neither, we at present know nothing. The nerve cells 
are in many cases entirely absent from these patches ; it is by 
some observers contended that they have been strangled by the 
neuroglia. It may be, however, that the neurogliosis is but a 
consequence, and not a cause, of their death. Where nerve cells 
occur they are rarely healthy, some being in a state of imperfect 
development, whilst others are atrophied and distorted (see 
Plate I., Fig. 5). The contiguous portion of the cortex is usually 
very irregular. The nerve fibres rarely show any acute degenera- 
tion, although the tangential and association pathways of the 
brain and the efferent tracts of the cord are often considerably 
diminished in size. The endothelial cells of the capillaries fre- 
quently contain black fatty granules, and in some of the sclerotic 
areas indications of old haemorrhage exist in the presence of 
haematoidin crystals. 

Bloodvessels. — As a rule the bloodvessels of the brain show 
little or no departure from the normal. Occasionally hyaline 
degeneration is present ; or there is a collection of pigment, 
similar to that in the nerve cells, disposed around the nuclei of 
the capillary endothelium. These conditions are not constant, 
and I do not think they have any causal relationship to the 
amentia. 

Situation of the Cellular Changes. — With regard to the layers 
in which these imperfections are most evident, it was stated by 
Bevan Lewis that embryonic cells were particularly numerous 
in the second and third cortical layers (the small and medium 
pyramids), and my own observations are entirely in agreement 
with this. Incompletely developed cells occur, it is true, in all 
the cortical layers, and in extreme cases of idiocy they may 



62 Mental Deficiency 

even be seen in the spinal cord ; but it is in the small and 
middle pyramidal cells that the greatest change is evident. In 
view of the fact that these cells are normally amongst the last 
to attain their full development, also that they are the earliest 
and most affected in dementia resulting from epilepsy and 
chronic insanity, this fact is of considerable interest. 

In cases of pronounced amentia these incompletely developed 
pyramidal cells are found in all regions of the cerebral cortex. 
There are, however, two situations in which they are most 
frequent, namely, the prefrontal and, to somewhat less extent, 
the parietal lobes. It would therefore appear that it is these 
regions which are chiefly concerned in the highest mental pro- 
cesses, for it is these same regions which show the greatest 
amount of degeneration in dementia. On this point the observa- 
tions of J. S. Bolton,* whose work on the morbid histology of 
the cortex cerebri is probably unsurpassed for painstaking care 
and completeness, are of great importance. Bolton concludes 
that " the cellular elements throughout the cortex cerebri which 
are specially concerned in the performance of associational 
functions are those of the pyramidal layer of nerve cells ; the 
great anterior centre of association of Flechsig in the prefrontal 
region is under-developed on the one hand in all grades of 
primary mental deficiency, and on the other hand undergoes 
primary atrophy pari passu with the development of dementia. 
This region of the cerebrum is therefore concerned with the 
performance of the highest co-ordinating and associational 
processes of mind." 

It is not improbable that the anatomical basis of psychic 
epilepsy and insanity will ultimately be proved to consist in an 
inherited instability, defective metabolism, or tendency to pre- 
mature degeneration of these cells, the actual exciting cause of 
the disease being supplied by any of the numerous forms of 
stress and strain incident to modern life. 

In concluding this account of the histological changes in 
primary amentia, it is necessary to remark that embryonic cells 
similar to those described (neuroblasts), are present in the 
normal adult brain, also that cells which appear to be of perfect 

* J. S. Bolton, "Amentia and Dementia," Journal of Mental Science 
April, 1905, et seq. 



Pathology 



63 



Plate II. 



Fibres *5£; 



Cells 




Fig. 9. — Microscopical Sections of the Frontal Cortex in Dementia, 
Amentia, and the Normal Conditions (Semi-Diagrammatic, 

DRAWN BY A. F. TREDGOLD). 

On the left of each are shown the fibres as they appear in sections stained by the Marchi-Pal 
method, on the right the cells as they appear in Nissl sections. The various layers are as 
follows : 

Fibres. — (1) Tangential, chiefly formed by the ramifications of the collateral processes from 
cells at A, B, C, and D, also the terminals of some of the fibres forming the medullary rays. 
This line is normally well defined; in amentia it is somewhat diminished, in dementia markedly 
so. (2) Super-radial. A few horizontally-coursing fibres are situated here, but this region is 
chiefly occupied by cells (Z?). (3) Outer line of Baillarger (line of Vicq d'Azyr), horizontally- 
coursing fibres composed of collaterals from cells at B, C, and /•', a well-marked line normally, 
much diminished in amentia and dementia. (4) Inter-radial, a less definite bundle, probably of 
similar constitution to (3), diminished in amentia and dementia. (5) White matter of centrum 
ovale. The vertical bundles are composed of axones from B, C, and D, and of rnedullated fibres 
from other regions of the brain. 

Cells. — (W) Neuroglia and small irregular nerve-cell-. (B) Small and (C) Medium 
Pyramids. In amentia there are comparatively few cells in these layers, and those present are 
irregular in arrangement and of incomplete development ; in dementia many of these cells are in 
an advanced state of degeneration. (D) Large pyramids, similar changes to those in the 
preceding layers, but not so extensive. (E) Polymorphous cells. It will be noticed that in 
amentia the whole cortex is much thinner than in the normal condition. This is principally due 
to the defective development of the cells at B, C, and D, but especially to those at B. 



64 Mental Deficiency 

development may be seen in the brain of the idiot, even of the 
most pronounced type ; but whereas in the normal the number 
of neuroblasts is comparatively small, and the great majority of 
the cells have attained complete development, in the latter the 
reverse is the case, the bulk of the eel's being in an immature 
condition, and many of them also showing further indications 
of defective function in the presence of considerable deposits 
of pigment. Moreover, the proportion of such immature cells 
appears to be directly related to the degree of mental deficiency, 
and in the milder degrees the microscopical condition is rather 
one of paucity of cells and irregular arrangement than of pro- 
nounced imperfection of the individual cells. 



The Histology of Secondary Amentia. 

As has already been stated, the difference between primary 
and secondary amentia is that, whereas in the former the full 
development of the neuroblasts cannot take place by reason of 
an intrinsic vital deficiency, in the latter their development is 
arrested by some external cause. This cause may operate 
generally, as in cretinism, or its effect may be local, as in acute 
polio-encephalitis or the vascular changes occurring in birth 
injuries. In many of these cases the nerve cells present similar 
histological features to those in the primary form, although it 
may be possible to infer that the condition is secondary from the 
localized nature of the agenesis and the presence of softening, 
sclerosis, chronic inflammation, or other signs of disease in an 
otherwise well-developed brain. 

In a considerable number of these secondary cases, however, 
degeneration of nerve cells subsequently takes place, this being 
often accompanied by more or less dementia. Where this 
happens, the detection of incompletely developed cells may be 
exceedingly difficult, just as the original amentia may be un- 
recognizable in the midst of the dementia. Such degeneration is 
a slow and chronic process, there being rarely any acute change 
discoverable by Marchi's method of staining. It begins as a 
chromatolysis, with accumulation of brownish-yellow granular 
pigment ; this is followed by a gradual atrophy of the axon and 
dendrons, and then by a shrinkage of the cell body. Later dis- 



Pathology 65 

integration of the nucleus and nucleolus occur, and this is often 
followed by sclerosis. 

The cerebral vessels sometimes show indication of this chronic 
degeneration in a thickening of their walls ; whilst the endothelial 
cells of the capillaries and the adventitia of the smaller arteries 
frequently contain a considerable deposit of brownish-yellow 
pigment (staining black with Marchi's fluid) similar to that met 
with in the nerve cells. 



Morbid Anatomy. 

Gross Developmental Anomalies and Pathological Lesions. — 

Although the essential pathological condition underlying amentia 
is one of imperfect or arrested development of the cortical cells, 
yet in a considerable proportion of cases anomalies of structure 
occur which are sufficiently gross to be recognizable by the naked 
eye. These fall under two headings, viz. : (1) Faults of develop- 
ment, and (2) Lesions resulting from disease. The former occur 
in cases of primary amentia only, and they are obviously a more 
gross manifestation of that same germinal blight which has 
produced the cellular imperfection. The latter are the after- 
effects of pathological processes which on the one hand produce 
secondary amentia, and on the other may complicate primary 
amentia. The following are the chief of these developmental 
anomalies and lesions : 

The brain of many mild aments, in its size, weight, and general 
appearance, may not be markedly different from the normal, 
but in the more pronounced degrees of mental deficiency differ- 
ences are usually obvious. I have never yet seen the brain of 
an idiot, a low or even medium grade imbecile, which could be 
regarded as normal upon careful naked-eye examination. Some- 
times it is too large, w r hen sections will show that it contains 
an excess of glia tissue. More often, however, it is too 
small, and the average weight of the encephalon of the ament, 
even excluding cases of microcephaly, is several hundred grammes 
less than the average of the ordinary population. In many 
instances the texture is either abnormally soft or unusually 
dense. In many cases, also, there is either a decided peculiarity 
in the whole configuration, or the convolutions are irregular 

5 



66 Mental Deficiency 

and of markedly diminished complexity. In addition there are 
often gross malformations of development. In cases of secondary 
amentia these changes may be little marked, but they are 
generally replaced by some obvious sign of disease. 

Malformations of the central nervous system vary from a 
trifling peculiarity of configuration or anatomical arrangement 
to a complete suppression of important structures, such as is 
seen in anencephalia, non-development of the medulla, or even 
absence of the spinal cord. Such severe conditions as these are, 
of course, incompatible with life, and even if the children were 
born alive, they could only survive a few hours. The malforma- 
tions ordinarily seen in post-mortem examinations of aments are 
much less severe, and are in most instances situate in the cerebral 
hemispheres or the cerebellum. This is doubtless owing, as 
Ziegler says, to the fact that these parts " in their development 
from the primary cerebral vesicles undergo the greatest amount 
of growth and the most important transformations." 

Most of these anomalies are forms of localized hypoplasia, 
which in some instances may be the result of disease or vascular 
occlusion ; in others, however, they are due to defects in the 
formative material of the brain. In the cerebral hemispheres 
the secondary, or < ven the primary, fi-sures may be imperfectly 
formed, there may be agenesis of a lobule or a whole group of 
convolutions, or there may be a general undergrowth of the 
whole of one hemisphere. This latter condition is called cerebral 
hemiatrophy, and the affected hemisphere may be from 200 to 
300 grammes weight less than the opposite one. In a consider- 
able proportion of cases a condition of microgyria is seen, in which 
a group of contiguous convolutions are represented by thin 
membranous folds, almost devoid of nervous tissue, and somewhat 
resembling the conduplication seen in the unexpanded petals of 
a flower-bud. Porencephaly* is another not uncommon patho- 
logical rinding, and is due to a non-development of the central 
convolutions around the inferior extremity of the Sylvian 
fissure. As a consequence, a deep funnel-shaped cleft is pro- 
duced which extends down to, and communicates with, the 
cavity of the lateral ventricle. This cleft is lined by the pia and 

* See Kundrat, "Die Porencephalic," Graz, 1882 ; also Audry, " Les 
Porencephalies," Revue de Medecine, June, 1888. 



Pathology 67 

bridged over by the arachnoid membrane, the contained space 
being filled with cerebro-spinal fluid. A somewhat similar 
depression may arise as the result of disease of the brain matter 
external to the lateral ventricle, which in many instances is 
brought about by a lesion of the Sylvian artery. This condition, 
as well as other circumscribed and cystic depressions of the brain 
surface, or even severe hemiatrophy, are often described as 
pseudo-porencephaly. 

Other more uncommon developmental anomalies of the 
encephalon consist of malformations of the basal ganglia, de- 
ficiency or absence of the corpus callosum, fornix, optic thalami, 
corpora quadrigemina, and corpora mammillaria. Arndt and 
Sklarek, in a post-mortem examination on an imbecile girl aged 
sixteen years who died in the Dalldorf Asylum, found that, in 
addition to deficiency of the corpus callosum, there were ab- 
normalities of the pillars and commissure of the fornix, of the 
gyrus fornicatus and fibres of the anterior commissure, as well as 
absence of the psalterium and septum pellucidum. They quote 
twenty-nine recorded cases of deficiency of the corpus callosum, 
most of them accompanied by other defects of brain structure, 
and the majority of the patients being idiots. 

Anomalies of the cerebellum consist chiefly of a general hypo- 
plasia, which occurs with considerable frequency in the Mongo- 
lian type of amentia, as well as of various forms of localized 
agenesis similar to those met with in the cerebrum. 

It is to be remarked that such lesions, whether due to faults 

of development or to disease, are very likely to interfere with 

the growth, or to cause degeneration, of other portions of the 

nervous system with which the affected areas are functionally 

related. Thus, in lesions of the motor cortex there is sclerosis 

of the corresponding efferent tract throughout the pons, medulla, 

J and cord, and corresponding to this there is often a numerical 

I diminution of the anterior horn cells of the cervical and lumbar 

i enlargements. Lesions of the basal ganglia may give rise to 

J secondary changes in the cerebellum and its superior peduncle 

j of the opposite side, also in the fillet and interolivary layer of 

j the pons and medulla of the same side. Lesions of the motor 

j cortex may even interfere with the development of the great 

association centres. In examining anomalies of the nervous 

5—2 



68 Mental Deficiency 

system, it is thus not always easy to disentangle those lesions 
which are primary from those which are in this way secondarily 
produced. 

Hydrocephalus is a not uncommon accompaniment of both 
the primary and secondary forms of amentia ; it occurs in two 
varieties. In one variety the excess of cerebro-spinal fluid occurs 
within the ventricles, and is then known as " internal hydro- 
cephalus." In the other it is situated external to the surface 
of the brain, and is then known as " meningeal hydrocephalus " 
or " hydrocephalus ex vacuo." 

The cause of Internal Hydrocephalus is often obscure. Some 
cases date from early embryonic life ; in others the condition 
first appears in early childhood. Both syphilitic and tuber- 
cular lesions have been found, and in other cases chronic 
thickenings of the choroid plexuses are seen. It is probable 
that the affection in many instances depends on closure of 
the communications between the cavities of the ventricles 
and the subarachnoid spaces in the transverse fissure ; but 
as to the causes bringing about this closure we know very 
little. On the other hand, there is no doubt that in some 
instances internal hydrocephalus may be secondary and com- 
pensatory to non-development of the brain tissue. This is 
probably so in those cases where it is confined to one ventricle, 
the substance of the corresponding hemisphere being thin and 
undeveloped ; also in those cases in which it accompanies a 
general hypoplasia of the cerebrum, such as occurs in micro- 
cephaly. Distension of the ventricles, even to a considerable 
extent, is a not very uncommon finding in microcephalic amentia. 

External Hydrocephalus is always compensatory to disease or 
non-development of the cerebral tissue. The excess of fluid is 
situate in the subarachnoid space, and always occurs in the 
vicinity of the local defects. In cases of general atrophy of 
the convolutions due to dementia, the dilated sulci are filled 
with pale, clear cerebro-spinal fluid. In conditions of localized 
disease, or agenesis, on the other hand, the fluid is confined to 
form a cyst. This is particularly well seen in some cases of 
pseudo-porencephaly. It may happen for internal and external 
hydrocephalus to be present in the same brain. 

Encephalitis and Meningoencephalitis. — These conditions are 



Pathology 69 

always indicative of a previous disease of the brain. They 
are therefore commoner in, but not restricted to, the secondary 
form of amentia. The cause is one or other of the toxic or 
vascular lesions which have already been described in the chapter 
on Causation ; but they have no constant relationship to any 
particular one of them. Encephalitis may result alike from 
cortical haemorrhages, thrombosis of the meningeal veins due 
to asphyxia, or a poisoning of the cortical cells. Sachs* con- 
siders chronic meningo-encephalitis to be a common result of 
the meningeal haemorrhages occurring during birth, but Freud 
is of opinion that these cases do not commonly terminate in a 
chronic inflammatory process between the membrane and under- 
lying brain surface. 

There can be no doubt that in the majority of cases of amentia 
which are due to, or accompanied by, " birth paralysis " (Little's 
disease), meningeal haemorrhage is present, although in occa- 
sional instances the haemorrhage may be within the brain cortex. 
Where the bleeding is from the membrane, the clot is usually 
between the pia and the brain surface, and it may be situated 
over the vertex or at the base. Holtf says that the posterior 
part of the base is much the more frequent site, and that a diffuse 
haemorrhage is commoner than is a single circumscribed clot. 
He further states that, whilst the quantity of blood extravasated 
varies from one drachm to four ounces, it is usually about 
one ounce. 

However produced, inflammation of the cerebral cortex 
usually leads to marked histological changes. In most cases 
there is considerable distortion of all the affected tissue, so that 
the lamination is exceedingly confused and irregular. In many 
cases the normal layers are almost indistinguishable, and the 
cortex consists of a haphazard collection of various-sized cells. 
Associated with this there may be a clear, pale layer devoid of 
cells at a little distance below the brain surface. In some cases 
areas of sclerosis are found, or there is a more diffuse pro- 
liferation of the neuroglia ; in other cases there are small 
localized softenings. The vessels are often numerous and the 

* Sachs, "A Treatise on the Nervous Diseases of Children," New 
York. 1895. 

f R. Holt, " Diseases of Infancy." 



jo Mental Deficiency 

perivascular spaces dilated ; whilst if the lesion occurs in the 
motor region, there is usually a chronic degeneration of the 
efferent tract, which may be traced through the medulla and 
cord. The term "agenesis corticalis " has been applied by 
Sachs to this condition where of intra-uterine origin. 

In meningo-encephalitis the pia-arachnoid is found to be 
considerably thickened, opaque, unduly vascular, and firmly 
adherent to the underlying brain tissue, from which it cannot 
be detached without causing decortication. In some cases 
the softening and disintegration of the brain substance is 
definitely circumscribed ; the space thus formed is filled with 
cerebro-spinal fluid, and bridged over by the investing membrane, 
forming a so-called arachnoid cyst. 

In a certain number of cases of amentia, even where there are 
none of these gross lesions, dementia supervenes. There is then 
usually found more or less atrophy of the convolutions, with con- 
siderable excess of fluid in the widened sulci, and in these cases the 
membranes are also thickened and opaque ; but the pia-arachnoid 
strips with unusual readiness, unlike the adhesion in chronic 
meningo-encephalitis. The dura-mater is sometimes firmly 
attached to the bone, and very occasionally osseous plates and 
subdural false membranes have been found. Apart from these 
conditions of disease or dementia, the membranes in persons 
suffering from amentia rarely show any pathological change. 

The Skull. — In most cases of primary amentia the skull is 
thicker and denser than normal, the diploe often being non- 
existent. In some instances the sutures are found firmly and 
prematnrely united, from which arose the erroneous notion that 
premature synostosis was a cause of idiocy. Where extensive 
cerebral hemiatrophy exists, whether from disease or congenital 
anomaly of development, there may be considerable asymmetry 
of the cranium as seen from the outside ; but it often enough 
happens that no external malformation is noticeable in this con- 
dition, the deficiency being associated with a considerable enlarge- 
ment of the inner table of the skull only. In some of these 
cases there is no bony overgrowth at all, the space being merely 
filled with an excess of cerebro-spinal fluid. The various 
anomalies of external configuration will be described in sub- 
sequent chapters. 



CHAPTER V 

CLASSIFICATION 

We have seen that there are two fundamentally different forms of 
amentia ; there are also innumerable degrees ; and it is convenient 
to describe certain distinctive clinical types. Unfortunately, the 
neglect of some authors to make these distinctions clear has had 
the effect of unnecessarily complicating the classification of mental 
deficiency, which is in any case a task of sufficient difficulty. 

The Forms of Amentia. 

The great majority of aments (probably about 90 per cent.) 
are the result of inherent defects of the germinal plasm — morbid 
heredity. In consequence of this blight, neuronic development 
is irregular and faulty, and a condition of primary amentia 
ensues. 

In about 10 per cent, of cases there is no morbid heredity and 
no inherent inability to develop, but the growth of some portion, 
or the whole, of the brain is interfered with, or arrested by, 
disease or other adverse environment. This condition may be 
called secondary amentia. 

At first sight these terms may appear to be synonymous with 
the older ones — " congenital " and " acquired." They are not 
so, however, for so-called " congenital " amentia may in reality 
be secondary and due to a factor of the environment operating 
in utero ; whilst what would be called " acquired " amentia 
may really be the result of a primary imperfection which has 
been made manifest through the contributory influence of some 
external factor. I think, therefore, that the terms " primary " and 
11 secondary " are not only more accurate, but materially assist our 
conception of the real nature of the condition present. As will 

71 



72 Mental Deficiency 

presently be seen, these two forms are not only essentially different 
in their etiology, but they often present totally distinct patho- 
logical, psychological, and physiognomical features. 

But whilst the majority of cases of amentia are readily referable 
to one or other of these two chief forms, there are a few which 
seem to be intermediate between them. In these morbid heredity 
is present, but the brothers and sisters of the patient are seemingly 
healthy, and the patient himself has seemed to be well in body 
and mind until the advent of some illness, " fright," or " fall," 
etc., in the early months or years of life. These cases have been 
called developmental, and the term is in some respects very 
convenient. But inquiries usually show that the exciting factor 
is of a comparatively trivial nature, quite disproportionate to 
the mental disability which follows, and such as would be 
incapable of damaging the nervous system of a healthy child. 
There can be no doubt, therefore, that in such cases the 
inherited condition of the nervous system is a factor of the 
utmost moment, and perhaps the term delayed primary amentia 
would best define the class. 



The Clinical Varieties of Amentia. 

In addition to the fundamentally different forms just de- 
scribed, persons suffering from amentia present minor differ- 
ences which are exceedingly useful as a means of dividing them 
into clinical varieties. It is here, however, that much confusion 
exists, for authors are by no means agreed as to the particular 
characteristics which should be used. Some would attempt 
to divide aments according to the particular cause at work ; 
but though this is practicable in the case of the secondary 
form, it is not so with regard to the primary. All these latter 
are the result of a germinal blight, and the effect is the same 
whether that blight is caused by alcohol, tubercle, or any other 
condition. Even with regard to the secondary group, the 
pathological condition would in many cases appear to afford 
a better means of classification than would the cause. 

The classification suggested by Ireland* is decidedly the best 

hitherto devised, but, as that distinguished author is the first 

* W. W. Ireland, " Mental Affections of Children," 1898. 



Classification 73 

to acknowledge, it is by no means perfect, and is, in reality, 
little more than an enumeration of the chief clinical varieties. 
Whilst still making use of most of Dr. Ireland's clinical groups, I 
believe that the investigations which have been made in recent 
years enable us now to arrange these groups in a much more 
systematic manner, and this I attempted to do in a table pub- 
lished several years ago. This table, in an improved form, is 
given on p. yy. 

The Clinical Varieties of Primary Amentia. 

The majority of persons suffering from primary amentia 
present no special distinguishing features other than the ana- 
tomical and physiological anomalies common to aments in 
general ; they may therefore be termed simple aments, and they 
correspond to the " genetous "* group of Ireland. In others, 
however, the imperfection of development, for some reason or 
other, has taken a particular form, and thereby produced marked 
cranial or physiognomical peculiarities ; since these are often 
associated with special mental characteristics, we are justified 
in alluding to them as separate varieties. The most important 
of these are the Microcephalics and the Mongolians.^ 

In a not inconsiderable number of primary aments (particu- 
larly of the simple variety) there exist severe gross lesions. In 
many cases these are only revealed after death, but it occasion- 
ally happens that they are so pronounced during life as to justify 
the use of them as a further means of classification. Accordingly, 
we may describe sclerotic, porencephalic, and (occasionally) 
hydrocephalic subvarieties of primary amentia. Epilepsy and 
paralysis are such common complications of all these cases that 
their presence can hardly be said to constitute separate varieties. 

The Clinical Varieties of Secondary Amentia. 

Cases of secondary amentia are divisible into two main classes, 
according as to whether the deficiency (1) is brought about by a 

* This term is open to the objection that all primary aments may in 
reality be called " genetous." 

•j- Negroid, Grecian, Egyptian, and American Indian types have also been 
described; but as these are rare, and their characteristics by no means 
definite, they will not be alluded to further. 



74 Mental Deficiency 

general or localized disease of the brain cells, or (2) is due to some 
external factor influencing their nutrition. 

Class 1. Amentia due to Cerebral Disease. — Diseases of the 
brain may, for our present purpose, be divided into two groups — 
first, epilepsy, secondly, gross lesions. These latter may arise 
from many different causes which have already been specified, 
and the lesions themselves present different anatomical features. 
As a consequence there are produced more or less well-marked 
clinical varieties. These varieties may be classified as follows : 

1. Epileptic and eclampsic amentia. 

2. Vascular, toxic, and inflammatory amentia, including 

certain special clinical types — i.e., 

Porencephalic. 

Sclerotic. 

Hydrocephalic. 

3. Syphilitic amentia. 

4. Infantile cerebral degeneration. 

Class 2. Amentia due to Defective Cerebral Nutrition, — The 
nutrition of the brain may suffer (1) in consequence of qualita- 
tive or quantitative anomalies of the blood-supply, or (2) as a 
result of the deprivation of nervous stimuli from without. 
Cretinism is the best-known and most important example of the 
former, although possibly other abnormal states of the blood 
may so act. The absence of the necessary nervous stimuli to 
development produces amentia from isolation or sense depriva- 
tion. The clinical varieties of this class are therefore enumerated 
as — 

1. Cretinism. 

2. Amentia due to defects of nutrition. 

3. Amentia due to isolation or sense deprivation. 

The Degrees of Amentia. 

Amentia varies greatly in its degree, irrespective of form or 
clinical variety. In some cases the defect is but slight ; in 
others it is so severe that mind can hardly be said to be present 
at all. Between these two extremes there is every gradation ; 
and since the differences are of quantity rather than quality, of 
degree and not kind, any classification must be an arbitrary one. 



Classification 75 

Esquirol suggested the faculty of speech as a dividing line ; but 
this is unsatisfactory, as there are quite mild aments who cannot 
speak. Sollier* proposed the faculty of attention ; but this is 
also far from being a reliable criterion as to the amount of defect. 
In fact, there is no one faculty or function upon the presence or 
absence of which we can rely as a means of defining the degree of 
amentia. 

Nevertheless, it is essential, both for purposes of description 
and administration, that a division should be made, and this, on 
the whole, is best done by means of three terms which have long 
been in use — namely, Feeble-mindedness, Imbecility, and Idiocy. 
To one or other of these degrees we may relegate all aments, 
although it is to be remembered that the boundary lines are by 
no means distinct, and that the one gradually merges into the 
other. We may, indeed, if necessary, further subdivide each of 
them into three others, and thus describe high-, medium-, and 
low-grade idiocy, imbecility, and feeble-mindedness respectively. 

A concise definition of these three terms is impossible, for the 
reason that they are used with reference to the amount of general 
intellectual capacity present ; but the chief characteristics of each 
are summarized in the following descriptions. A definition of 
amentia has already been given on p. 2. 

Feeble-Mindedness (High-Grade Amentia). — This is the mildest 
degree of mental defect, and the feeble-minded person is " one 
who is capable of earning a living under favourable circumstances, 
but is incapable, from mental defect existing from birth, or from 
an early age, (a) of competing on equal terms with his normal 
fellows ; or (b) of managing himself and his affairs with ordinary 
prudence, "f 

Feeble-minded persons under the age of sixteen years come 
within the jurisdiction of the education authority by reason of a 
special Act of Parliament (Defective and Epileptic Children 
Act, 1899). On account of this Act they are commonly desig- 
nated mentally defective children, and they are defined as " those 
children who, not being imbecile, and not being merely dull and 

* P. Sollier, " Psychologie de 1' Idiot et de 1' Imbecile," Paris, 1891. 

•j- This and the following definitions were suggested by the Royal College 
of Physicians of London, and adopted by the Royal Commission on the 
Feeble-Minded as the basis of classification in their inquiries. 



76 Mental Deficiency 

backward, arc, by reason of mental deject, incapable of receiving 
proper benefit from the instruction in the ordinary public elementary 
schools, but are not incapable by reason of such defect of receiving 
"it in such special classes or schools as are in this Act men- 
tioned." 

It should be remarked that in America the term " feeble- 
mindedness " is not thus used specifically of the mildest degree 
of amentia. In that country it is applied generically to the 
whole order of amentia, thus being synonymous with the English 
term " mental deficiency." There has been an attempt in this 
country also to include all grades of defect in this euphemistic 
description, and to call the mildest degree of all (the feeble-minded) 
" mental defectives." The attempt has not met with much suc- 
cess, however, and since " feeble-mindedness " is in itself a more 
specific term than is "mental defect," I think it is decidedly 
better to restrict its use to the mildest degree. 

Imbecility (Medium-Grade Amentia). — The imbecile is defined 
as ' ' one who, by reason of mental defect existing from birth, or from 
an early age, is incapable of earning his own living, but is capable 
of guarding himself against common physical dangers."* 

Idiocy (Low-Grade Amentia). — The idiot is defined as " a 
person so deeply defective in mind from birth, or from an early 
age, that he is unable to guard himself against common physical 
dangers"* 

It may be remarked that these three terms are occasionally 
used of varying degrees of Amentia, particularly the dotage of 
old age, just as " mental deficiency " is sometimes used generally 
for that condition. The practice, however, is to be deprecated 
as likely to lead to considerable confusion. 

In addition to the above, it may perhaps be well in this place 
to define the moral imbecile as "a person who displays from 
an early age, and in spite of careful upbringing, strong vicious or 
criminal propensities, on which punishment has little or no deterrent 
effect" 

* See note p. 75. 









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CHAPTER VI 

THE PHYSICAL CHARACTERISTICS OF AMENTIA 

We have seen that, in an overwhelming proportion of persons 
suffering from amentia, the condition is the result of a blighted 
germinal plasm. The effect of this upon development will 
naturally be greatest in the case of the organ of most delicate 
and complicated structure — namely, the nervous system. In 
mild cases this alone may be involved, and it may even happen 
that the injurious effect is limited to the least organically fixed 
structures of this system — that is, to the neurones subserving the 
highest mental processes. 

But such cases are relatively few. The majority of aments are 
the product of a markedly abnormal germinal plasm, and, as a 
consequence, not only the brain, but the whole body is marred 
by defects of anatomical development and physiological function. 
Such defects are known as stigmata of degeneracy. 

Stigmata of Degeneracy. 

In recent years much has been said and written about degene- 
racy, and the most elaborate tables of its " stigmata " have been 
compiled. These have been divided into social, psychological, 
physiological, anatomical, and other groups, and some writers 
would seem to look upon any departure from their conception 
of what is or should be the normal social, psychological, physio- 
logical, anatomical, or other condition, asa" stigma " of degene- 
racy. I do not think this view is justifiable. In the first place, 
there are so many variations within healthy limits that the 
" normal " becomes exceedingly difficult to define. Moreover, 
it by no means follows that a condition which is uncommon, or 
even " abnormal," is on that account a mark of degeneracy, or 



The Physical Characteristics of Amentia 79 

that it is even pathological at all. We have not yet reached 
finality, and manners, morals, mind, physiological function, even 
anatomical structure, are, we trust, still in process of evolution ; 
so that it is possible for some of these anomalies described as 
"stigmata" to be not retrogressive, but actually progressive. 

But even where they are undoubtedly pathological or indica- 
tive of a diseased condition, it does not follow that on that 
account they are stigmata of degeneracy. As has already been 
shown, there are some diseases and toxic states of intra- or early 
extra-uterine life which are occasionally capable of producing 
secondary amentia, and in these cases, although the germinal 
plasm is healthy, there may nevertheless be produced physio- 
logical and anatomical anomalies. There are also other diseases, 
such as rickets and syphilis, which rarely produce mental defi- 
ciency, and yet which commonly result in bodily abnormalities. 
Even in cases of undoubted degeneracy, such as primary amentia, 
some of the bodily conditions which are commonly called " stig- 
mata " seem to me to be not a concomitant effect of the germina 
imperfection, but the result of the imperfect nervous action. 
Lastly, the examination of perfectly healthy children in public 
elementary schools, as well as of ordinary healthy members of 
the general population, will often reveal the presence of so-called 
" stigmata." In fact, if we are to class as degenerates all persons 
coming within the territory defined by some writers on this 
subject, there are few of us who will escape. 

I am far from denying the existence of degeneracy and its 
stigmata. In fact, I consider primary amentia itself to be a 
true degeneration, and many of the anomalies of bodily condi- 
tion present in these persons may rightly be described as " stig- 
mata " of degeneracy. But I think we should be careful to 
restrict this term to such anomalies as are really manifestations 
of this state — that is, to peculiarities which are due to inherent 
defects of the germinal plasm. In the present state of our know- 
ledge this differentiation cannot always be made. Some — indeed, 
many — of the physical characteristics of amentia to be described 
are certainly the result of degeneracy, and it is not surprising 
that such should be numerous and severe in this condition, in 
the lower degrees of which degeneracy reaches its culminating 
manifestation. But some of these characteristics are not really 



So Mental Deficiency 

degenerative. I shall therefore prefer to describe them all 
under the heading of " Anomalies of Anatomical Development 
and of Physiological Function." 

It has been remarked that similar anomalies occur in persons 
who are not otherwise abnormal. Nevertheless, it is abundantlv 
clear that they are far more numerous in neuropaths and in 
aments than in the general population. Further, that their 
number and severity is, on the whole, directly proportionate to 
the degree of defect. Whilst, therefore, the presence of a single 
anomaly has little or no diagnostic importance, the presence of 
two, three, or more is of considerable significance as an indication 
of mental defect. 

The table on pp. 82-83 shows the various anomalies which have 
been noted in amentia ; the chief of these may now briefly be 
described. 

Anomalies of Anatomical Development. 

A. Nervous System. — These have already been described in 
the chapter dealing with pathology. 

B. Special Sense Organs. — Ear. — It is probable that, owing 
to important alterations which have taken, and are taking place 
in the sense of hearing, the external ear is at present in a state 
of considerable evolutionary instability. It is, therefore, not 
surprising to find that anomalies of this structure occur in normal 
persons, amongst whom, as a matter of fact, they are extremely 
common. This being the case, it is evident that, as an indica- 
tion of degeneracy, such anomalies are in themselves of little 
value, and I must dissent from the dogmatic utterances of some 
writers that a certain type of ear can be labelled " criminal," 
another " insane," and so on. At the same time, there is no 
doubt that, frequent as are such departures from the normal in 
the ordinary population, they are still very much more frequent 
in degenerates ; and when they occur in combination with two 
other classes of defects — namely, of the cranium and palate — I 
believe that they have considerable diagnostic value. 

With regard to the frequency of auricular defects, the following 
figures ascertained by Gradenigo,* although they do not relate 

* Gradenigo {Arch, de Psychiatria, 1890 and 1892), quoted by Talbot in 
" Degeneracy." 



The Physical Characteristics of Amentia 81 

specifically to amentia, are of considerable interest. As the 
result of his examination of several thousands of persons of both 
sexes, this observer found that the external ears were regular and 
normal — 

In 56 per cent, of males and 66 per cent, of females of the 

ordinary population. 
In 36 per cent, of males and 46 per cent, of females of the 

insane population. 
In 28 per cent, of males and 54 per cent, of females of the 

criminal population. 

Also that in the insane and criminal classes, not only were ear 
anomalies more frequent, but they were of greater gravity. As 
tending to show that some ear anomalies may be progressive 
rather than retrogressive, it may be stated that Talbot found 
certain varieties were more frequent in ordinary persons than in 
degenerates. 

The varieties of malformation of this structure which are met 
with in persons suffering from amentia are so numerous that a 
detailed account of them all is impossible. There is no portion 
of the external ear which may not be affected, but the following 
are the chief conditions met with : Defects of the lobule are 
decidedly the most frequent ; it is often unusually large and 
fleshy ; it may, however, be smaller than usual, and at times 
even absent ; it is occasionally adherent to the face. Another 
very common deformity is that in which the whole ear is ex- 
cessively large, prominent, and outstanding, with a marked 
convexity as seen from behind. Another common type is the 
reverse of this, the entire pinna being small, thin, and circular, 
strongly recalling the ear of the chimpanzee. With or without 
any of these gross changes there may be numerous minor mal- 
formations of the helix and antihelix, the tragus and antitragus. 
Supernumerary auricles are occasionally present, but I do not 
think that anomalies of the Darwinian tubercle are more frequent 
in aments than in the normal population. It occasionally 
happens that the auditory apparatus is so imperfectly developed 
that total or severe deafness results. This, however, is un- 
common, and deafness, when present, is usually the result of 
disease, especially suppuration of the middle ear. 

6 



82 



Mental Deficiency 










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84 Mental Deficiency 

Eye. — Anomalies of the eye and its appendages are exceedingly 
common in aments, those most frequently seen being the fol- 
lowing : Epicanthus, a ridge of skin continued from the upper 
eyelid around the inner canthus, and apparently due to an 
unusual redundancy of skin in this region ; it may be unilateral, 
but usually affects both eyes, and is a tolerably frequent anomaly 
in aments, although not unknown in normal children. Palpebral 
fissures, which are small and obliquely placed, so that the inner 
is lower than the outer end, are a characteristic feature of the 
Mongolian variety of amentia. Differently coloured and speckled 
irides are very common, as also are strabismus, astigmatism, 
hypermetropia, and less frequently myopia. Corneal opacities 
are frequent, but colour-blindness does not appear to be more 
prevalent than in the ordinary population. 

Nose. — A clear-cut, well-formed nose is not often seen in 
aments, and this organ is usually either considerably flattened 
or depressed, or is large and prominent, with wide fleshy nostrils 
which look forwards rather than downwards. Deviation of the 
septum and nasal bones may also occur. 

The Lips are often thick, coarse, prominent, and unequal in size. 
The mouth is heavy and flabby-looking, generally open, and 
devoid of either refinement or firmness. Hare-lip is not common. 

The Tongue is often abnormally large, fissured, and its papillae 
hypertrophied, particularly in the Mongolian variety. 

C. Osseous System. — Abnormal conditions of the skeleton 
occur with extreme frequency in amentia, and the number of 
these persons who do not present one or more well-marked bony 
anomalies is small. The cranium, palate, jaws, and teeth, are 
the parts most frequently affected. 

Cranium. — Anomalies of the cranial vault may be revealed by 
inspection, palpation, and mensuration ; also by tracings from 
pliable metal bands which have been moulded to the skull. 
Provided this latter method is carefully performed, it yields very 
accurate results, and Dr. Lapage* has recorded a most interesting 
series of observations taken in this way. The process, however, 
is somewhat too tedious for general work, and I think that for 
practical purposes mensuration is the most suitable. The fol- 
lowing are the measurements I have been in the habit of taking 

* C. P. Lapage, " Feeble-Mindedness in Children," Medical Chronicle, 
1905. 



The Physical Characteristics of Amentia 85 

for several years ; they have the advantage of being easily carried 
out and recorded. 

The measurements are taken from the upper point of attach- 
ment of the auricular pinna to the lateral aspect of the skull. 
This point was suggested to me many years ago by Dr. J. S. 
Bolton as being readily ascertainable in every case, and subject 
to little individual variation ; it is designated " X." From the 
fixed point " X " of one side a steel tape-measure is passed in 
various directions to the corresponding point on the opposite 
side — namely, (a) over the glabella, (b) over the greatest frontal 
prominence, (c) vertically upwards, (d) over the greatest parietal 
prominence, (e) over the external occipital protuberance. An 
additional sagittal measurement is taken from the glabella over 
the cranial vault to the external occipital protuberance, and, if 
desired, a further measurement can be taken with the calipers 
between the two points " X." 

These measurements are conveniently recorded by means of a 
diagram like the following, which can be rapidly drawn as occa- 
sion requires, or printed in one corner of the case-sheet : 




Fig. 10. 

It will be observed that the measurement XAX plus XEX gives the cranial 
circumference, XCX its vertical perimeter, and XBX and XDX the 
greatest frontal and parietal perimeters respectively. If the circumference 
be multiplied by XBX and XDX, a figure is obtained which is a con- 
venient index of the total cerebral capacity. 

The general conclusion at which I have arrived, as the result 
of an extensive series of measurements of the crania of normal, 
insane, epileptic, and defective persons, is that, in the majority 
of aments there are marked departures from the normal ; but 
that there is no particular type of skull which is characteristic 
of that condition. The chief anomalies are the following : 
Circumference : The average normal circumference of the male 
adult is 22 inches, and of the female 2ij inches. Occasionally 
the skull of the ament exceeds these figures, but as a rule it is 



86 Mental Deficiency 

decidedly less,' and in cases of microcephaly it is often as little 
as 15 inches. There is often a diminution of the frontal and 
parietal perimeters, whilst a subnormal .development of the 
occipital portion of the skull is exceedingly common. Sym- 
metry : The two halves of the normal skull not infrequently 
differ slightly in size, but this condition is much commoner and 
far more marked in aments. Where paralysis has existed from 
an early age, this condition is very frequent, the lessened measure- 
ment corresponding to the area of brain destroyed or arrested in 
its development, but asymmetry of the cranium is often observed 
in the absence of any paralytic signs. Usually the left half is the 
smaller. Lapage found that lateral asymmetry occurred in 158 
cases out of a total of 198, the left half being the smaller in 122, 
and the right in 36. Cranial bosses are frequently present, 
probably as a result of rickets, the most common situations being 
the ossific centres of the frontal and parietal bones. In a few 
cases an interfrontal ridge is seen. Finally, the whole conformation 
of the skull may be abnormal, as is seen in the oxycephalic type. 

Palate. — The association of abnormalities of the palate with 
mental deficiency has long been recognized, and there is no 
doubt that it is one of the commonest malformations occurring 
in this condition. Many years ago Langdon Down* drew atten- 
tion to the subject, and more recently Cloustonf has recorded a 
large number of observations which show conclusively that, 
although deformed palates occur in the normal, they are far 
and away more frequent in neuropaths and the mentally defec- 
tive. He states that deformed palates are present in 19 per 
cent, of the ordinary population, 33 per cent, of the insane, 55 per 
cent, of criminals, but in no less than 61 per cent, of idiots. 
Petersen, J who has made a most exhaustive study of this ques- 
tion, and has compiled an elaborate classification of the various 
anomalies, found palatal deformities present in no less than 
82 per cent, of idiots. 

Without going into ultra-refinements, it may be stated that 
the majority of the anomalies met with may be arranged under 
two headings as follows : 

* J. Langdon Down, Transactions of the Odontological Society of 
Great Britain, 1871. 

f T. S. Clouston, " Neuroses of Development," 1891. 

% Petersen and Church, " Nervous and Mental Diseases," 1904. 



The Physical Characteristics of Amentia 87 

1. Saddle- or Keel-shaped Palates. — In this, the commonest 
type, there is a contraction of the alveolar arch between the 
bicuspid and molar teeth, the palate at the same time extending 
upwards to a considerable distance, at the expense of the nasal 
cavity. In consequence an appearance like the inside of a 
saddle or boat's keel is produced. It is sometimes marked by a 
narrow central antero-posterior furrow, but the front teeth do 
not usually protrude in this type of palate. 

2. V-shaped Palates. — These are not so frequent as the former, 
and are produced by a gradual narrowing of the dental arch 
from the first molars to the central incisors, the point of the 
V being thus directed forwards. Palates of this type may also 
be higher than normal, and the narrowing of the fore-part of the 
arch usually causes considerable overcrowding and protrusion of 
the front teeth. 

A great deal of discussion has raged round the cause and 
manner of production of these anomalies.* It has been con- 
tended by E. S. Talbot that they only appear during the second 
dentition, between the sixth and twelfth years ; but this is 
denied by Clous ton, John Thomson, and other physicians of 
great experience, and I have certainly seen numerous instances 
before this period. I think there can be little doubt that most 
of them are real stigmata, and a further indication of those 
formative defects which play such a prominent part in the 
production of amentia. At the same time it is to be remem- 
bered that the palate, like the external ear, is probably under- 
going considerable evolutionary changes, and many of the slighter 
anomalies may be due to this cause. 

Cleft palate appears to be on quite a different footing, and it 
is doubtful if this condition and its common associate, hare-lip, 
can be regarded as real stigmata of degeneracy. It is but rarely 
met with in amentia, Langdon Down finding it only in 0*5 per 
cent., and Ireland in 1 per cent., of idiots; whilst Talbot f ex- 
amined 1,977 feeble-minded children without meeting a single 
instance. These proportions do not differ materially from the 
normal, for Grenzer (quoted by Talbot) found 9 cases on 
examining 14,466 presumably normal children. 

* See the chapter on " Genetous Idiocy " in Ireland's book. 
f Talbot, " Degeneracy." 



88 Mental Deficiency 

Jaws. — Many aments have a receding, others a protruding, 
mandible, the former being very common in microcephalics. 
Asymmetry of the upper or lower jaw is not uncommon. 

Teeth. — Considering the frequent occurrence of deformities of 
the palate, it is not surprising to find that anomalies of the teeth 
are very common, and a good set of teeth is exceedingly rare in 
the mentally defective. They are usually late to appear, mal- 
formed, and unhealthy when present, and prone to early decay 
and disappearance. Where a V-shaped palate is present, the 
upper incisors and canines are generally huddled together and 
protruding, at times to such an extent as to be left uncovered by 
the lip. The remaining teeth may be very irregular in arrange- 
ment, and there are often large gaps between them. The wisdom 
teeth are seldom seen. It often happens that the teeth erupt at 
different planes of the alveolus, and I have occasionally seen a 
complete double row of incisors. In addition, the teeth are indi- 
vidually ill-formed, often honeycombed or marked by trans- 
verse striae, very unhealthy, and surrounded by a foul mass of 
exudation. 

Other defects of the osseous system are seen in the presence 
of talipes, polydactylism, syndactylism, and other deformities 
of fingers and toes. The arms are often disproportionately long. 
Very exceptionally a condition of gigantism is present. As a 
rule, however, the stature is diminished, and the average height of 
aments is several inches less than that of the ordinary population. 

D. Muscular and Cutaneous Systems. — Various anomalies of 
the skeletal muscles have been found upon dissection, but they 
are hardly of sufficient importance to merit further description. 
Abnormalities of the skin are frequent, and consist of coarseness 
of the integument, excessive and unpleasant secretion, webbing 
of the fingers, moles, and naevi. There is often an excessive 
development of hair upon parts usually hairless, and a lack or 
deficiency upon those which are generally covered, particularly 
the face and chin in males. 

Adenoma Sebaceum. — In this place reference may be made to 
this peculiar condition of the skin sometimes seen in aments, and 
with extreme rarity in normal individuals. Adenoma sebaceum 
is a papular new growth which is confined to the face, and is 
chiefly seen on the side of the nose, but occasionally on the fore- 



The Physical Characteristics of Amentia 89 

head or chin. It is usually, but not always, symmetrical, and the 
lesions are often numerous. They are either firmly imbedded in, 
or project from, the skin, and they vary in size from a pin-head 
to a small pea. They are of a whitish or yellowish colour, but 
sometimes bright red owing to numerous telangiectases. The 
papules are made up of an overgrowth of sebaceous glands and 
capillary vessels, often surmounted by a thickened corium. In 
many cases they are present at birth, but in others they do not 
appear until late in childhood or puberty. As a rule, they persist 
throughout life, but occasionally undergo spontaneous involu- 
tion with scarring.* 

E. Circulatory and Respiratory Systems. — The most impor- 
tant anomalies are stenosis of the pulmonary artery and defects of 
the auricular and ventricular septa. The heart also is usually 
smaller than that of a normal person of corresponding weight. 

F. Alimentary System. — Numerous anomalies of the various 
organs of this system have been observed upon dissection. 
Meckel's diverticulum is not very rare, and Talbot states that the 
appendix is best developed in degenerates. 

G. Urinary and Generative Systems. — Lobulation of the 
kidneys is not uncommon, and anomalies of the genital organs 
are of considerable frequency. These consist, in the male, of epi- 
and hypospadias, infantile condition of the penis, and crypt- 
orchism ; in the female, an infantile condition of the uterus is 
generally present, and the ovaries are often fibrous. Cloacal 
openings have been observed in both sexes. Supernumerary 
mammae are common. 

Anomalies of Physiological Function. 

It is, of course, to be expected that organs which are the site of 
grave defects of structure or anomalies of anatomical develop- 
ment should also be imperfect in their physiological function. 
Thus, the condition of the heart leads to an enfeebled circula- 
tion, so that cyanosis and coldness of the extremities, chilblains, 
and sores are exceedingly common. Defects of the organs of 
special sense are a factor in producing a diminished perceptivity. 
Xon-development of cortical areas or the internal structures of 

* See Pringle, British Journal of Dermatology , 1890, vol. ii., and Crocker, 
" Diseases of the Skin," 1893. 



90 Mental Deficiency 

the encephalon cause various degrees of paralysis, with their 
accompanying deformities. Indeed, the mental deficiency itself 
may be considered as an imperfection of physiological function due 
to neuronic changes, whilst the various neuroses and psychoses, 
such as insanity, epilepsy, hysteria, and one-sided genius, as well 
as the moral perversions, seen in prostitution, inebriety, and 
other anti-social and criminal tendencies, are of the same order. 

With regard to the functions of the generative organs, there is 
no doubt that many of these persons can propagate their kind, 
and there are, unfortunately, numerous examples where this has 
taken place. The milder aments, indeed, appear to be unusually 
prolific. At the same time, in the male sex, the advent of 
puberty is often considerably delayed, and may not appear until 
late in the teens. In the male this subject has been very fully 
investigated by Bourneville and Sollier,* who drew attention to 
a considerable retardation of puberty, as well as to the presence 
of frequent anatomical anomalies like those referred to. In the 
female, on the other hand, a similar retardation does not appear 
to be the case, and it is stated by Jules Voisin,f who has studied 
the subject closely, that the development of puberty takes place 
at a normal age, and that menstruation recurs at regular periods. 
Doubtless of many, or even most, female aments this is true, and 
amenorrhcea and dysmenorrhea do not appear to be commoner 
in them than in those of normal intelligence ; indeed, the latter 
seems to be less so. It is, however, to be remembered that in 
some of the pronounced idiots menstruation never appears at all. 

A similar retardation of physiological activity is seen with 
regard to dentition, speech, and walking. Inquiries show that a 
large proportion of aments do not cut their first or second teeth 
until some considerable time after the ordinary period. Many 
of them do not attempt to stand until their third year, and 
walking is correspondingly late. In many cases the child is four 
or five years old before it says a word. 

But in addition to these functional defects of particular organs, 
many aments are characterized by a physiological inadequacy 
which is general and widespread. Their temperature-regulating 

* Bourneville and Sollier, " Anomalies des Organes Genitaux chez les 
Idiots et les Imbeciles," Progres Medical, 1888. 
f Jules Voisin, " L'Idiotie." 



The Physical Characteristics of Amentia 91 

mechanism is so imperfect that colds and chills are exceeding 
common. Their metabolism is so defective that, in spite of 
abundance of wholesome food, most of them remain small, 
stunted, and ill-nourished. They have an increased predisposi- 
tion to illness, and readily contract disease, and their physio- 
logical margin and power of resistance are so diminished that 
disease quickly proves fatal. In fact, the history of a very large 
proportion of these patients may be expressed in two words — 
defective vitality — and the supervision of the physician is often 
as necessary for their bodily as for their mental ailments. Lang- 
don Down remarked the fact that " many cases of imbecility, 
particularly those of the Mongolian variety, lose a large amount 
of intellectual energy in the winter — go through, in fact, a process 
of hybernation, their mental power being always directly as the 
external temperature." 

Mortality. 

The physical welfare of the ament of to-day is the subject of 
far more care and attention than was the case a few generations 
back. Then many perished who, under present conditions, 
would have survived ; and there can be no doubt that modern 
medical and surgical practice, together with advances in pre- 
ventive medicine, have diminished the mortality rate, not only 
of the fit, but of the unfit also. 

Nevertheless, the virility of aments as a class is decidedly 
inferior to, and their expectation of life still less than, that of 
the ordinary population. Even amid the well-ordered sur- 
roundings of an institution the number of these persons of at all 
advanced age is relatively small, and in the world outside the pro- 
portion is still less. I am disposed to think that the mortality has, 
generally speaking, a direct relation to the degree of deficiency. 

This diminished expectation of life is well shown by some 
figures collected by Dr. Shuttleworth* with regard to Earlswood 
and the Royal Albert Asylums. These are shown in the fol- 
lowing table, together with the mortality at corresponding age 
periods of the whole population, as given by the Registrar- 
General. The difference between the mortality of aments and 
the general population is very striking. 

* Quoted by Ireland. 



9^ 



Mental Deficiency 



TABLE IX. 

Relative Mortality of Aments and Non-Aments. 



Age Periods. 


Death-Rate per 1,000. 


Aments (Dr. Shuttle- 
worth). 


Whole Population 
(Registrar -General). 


5 to 10 years . . 
10 ,, 15 

15 ,, 20 


50-I 
33-9 
45-i 


6-IO 

3-35 
475 



With regard to age periods, through the kindness of Dr. C. 
Caldecott, Medical Superintendent, and Dr. F. H. Pearce, 
Assistant Medical Officer, Earlswood Asylum, I have been 
supplied with particulars of 1,000 consecutive deaths in that 
institution. Owing to the impracticability of ascertaining the 
number of persons alive at corresponding ages, these figures 
cannot, of course, be compared with the mortality tables relating 
to the general population. They are, nevertheless, of consider- 
able interest, and are shown in the following table : 



TABLE X. 

Showing Age Periods of 1,000 Consecutive Deaths in Earlswood 
Asylum, dating back from October, 1907.* 





Males. 


Females. 


Under 5 ye 

5 to 9 , 

10 ,, 14 , 

15 » 19 . 
20 ,, 24 , 

25 „ 34 , 
35 » 44 , 
45 .> 54 , 
55 » 64 , 
65 „ 74 , 
75 » 84 , 


ars . 


• 






2 

70 

162 

180 

88 

66 

37 

22 

20 

6 


1 
40 

7i 

101 

42 

38 

28 

12 

9 

4 

1 


Total 






653 


347 












i.c 


>oo 



* Patients under the age of six are not eligible for the institution, 
excepting those that come in on payment scales. 



The Physical Characteristics of Amentia 93 

The following table, also kindly supplied by Dr. Caldecott, is 
of interest as showing the percentage of deaths to the number of 
patients in residence at Earlswood Asylum over a period of 
seventeen years. It is impossible by means of these figures to 
institute an accurate comparison between the mortality of 
aments and of the general population; for the reason already 
mentioned ; nevertheless, they afford clear evidence of the ex- 
cessive mortality rate in aments. The crude annual death-rate 
per 1,000 persons living, of all ages and both sexes, in England 
and Wales varies with different decennia, but is well under 20, 
whereas we see that even in a well-equipped and excellently 
managed institution like Earlswood the average mortality is 
over 30 per 1,000, and this relates to a selected age class, there 

TABLE XI. 

Showing the Percentage of Deaths to the Number of Patients in 
Residence at Earlswood Asylum over a Period of Seventeen 
Years, from December 31, 1890, to December 31, 1906. 



Year. 


Average Number 
Resident. 


Died. 


Percentage of Deaths 

to Average 

Number Resident. 




Males. 


Females. 


Total. 


Males. 


Females. 


Total. 


Males. 


Females. 


Total. 




1890 


418 


191 


609 


8 


7 


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Mental Deficiency 



being a disproportionately small number of persons over middle 
age and practically none under six years, so that the two most 
vulnerable life periods are excluded. 



Causes of Death. 

I am greatly indebted to Dr. Caldecott and Dr. F. H. Pearce 
for supplying me with the particulars of the cause of death in 
1,000 consecutive deaths at Earls wood Asylum which are shown 
in Table XII. These figures are not, of course, to be con- 
founded with the mortality rates of these diseases. Neverthe- 
less, they are exceedingly valuable as showing the relative 
incidence of various fatal diseases in aments. 

It is seen from this table that by far the commonest cause of 
death is tuberculosis, which accounts for 39-6 per cent., or nearly 
two-fifths, of those dying. The fatal varieties of this disease are 
as follows : 



Pulmonary Tuberculosis 
General ,, 
Meningeal ,, 
Abdominal 
Osseous „ 


Males. 


Females. 


Total. 


199 

37 
10 

9 
6 


106 

17 

1 
8 
3 


_ 

305 

54 

11 

17 
9 


261 


135 


396 



The next most common cause of death is epileptic convulsions, 
which claims 177 per cent, of the total ; whilst pneumonia is a 
very good third, being responsible for 10*4 per cent, of total 
deaths. It is interesting to note that, excluding tubercle, the 
nervous system is the part most frequently involved by fatal 
disease, being followed in order by the respiratory, circulatory, 
alimentary, and urinary systems. Not that diseases of the 
nervous system are the cause of the mental deficiency, but because 
the imperfection of development and imperfect function of the 
nervous system render it peculiarly prone to disease. 

I do not profess to institute an accurate comparison between 
the frequency of the various causes of death in these aments and 



The Physical Characteristics of Amentia 97 

in the general population. Such is impossible, for many reasons 
which will at once be obvious to the student of vital statistics. 
It may be stated, however, that according to various Reports o f 
the Registrar-General, it appears that of the total deaths through- 
out England and Wales approximately 12 per cent, are due to 
diseases of the nervous system ; 8 per cent, of the circulatory 
system ; 18 per cent, of the respiratory system ; 5 per cent, of 
the digestive system ; and 2 per cent, of the urinary system ; 
whilst from 10 to 12 per cent, are due to pulmonary and other 
forms of tuberculosis. In these aments, on the other hand, 
23*6 per cent, of the total deaths are from diseases of the nervous ; 
4*9 per cent, of the circulatory; 12*6 per cent, of the respiratory ; 
4'3 per cent, of the digestive ; and i'i per cent, of the urinary 
systems ; whilst 39*6 per cent, are due to some form of tubercu- 
losis. 



CHAPTER VII 

NERVOUS AND MENTAL CHARACTERISTICS OF AMENTIA 

In addition to their general deficiency of intellect, many aments 
present certain other particular and important psychological 
anomalies, as well as irregularities and defects of sensory and 
motor function. These will be described in the present chapter ; 
in so doing, it will be convenient to consider them under the three 
headings, Sensory, Mental, and Motor Processes. 

Sensory Processes. 

The brain of the new-born child consists of a gelatinoid sub- 
stance in which are imbedded myriads of embryonic nerve cells. 
These cells, or neuroblasts, however, are so immature that the 
child may be said to be mindless. Mental development proceeds 
by slow and orderly steps, and one of the most important means 
by which it is brought about is the stimulation of these cells by 
impressions entering through the sensory channels. Should one 
of the senses be diseased or defective, a corresponding area of 
the brain will remain permanently undeveloped, and this may 
lead indirectly to the non-development of other portions which 
are functionally correlated. Should communication with the 
outer world be closed via several sensory pathways, the growth 
of the brain may be so much interfered with as to produce a 
condition almost amounting to idiocy, and known as " amentia 
by sense deprivation." As instances of this, the celebrated 
cases of Kaspar Hauser and Laura Bridgman may be referred 
to. Considered, therefore, merely from the point of view of 
their stimulating effect upon the brain cells, sensory impressions 
are as necessary to mental development as are the rays of the 
sun to the growth and maturation of plant life. 

98 



Nervous and Mental Characteristics of Amentia 99 

This, however, is not their only effect. Sensations are the 
basis of ideas, and a comparison of ideas constitutes reasoning ; 
so that although the ability to receive impressions and the 
ability to examine, combine, compare, and work up these impres- 
sions are two totally distinct functions, yet the wealth of sensa- 
tions is a factor which cannot be ignored in considering the 
quantity, if not the quality, of mental activity. In somewhat 
crude language, we may say that sensations are the materials 
of which " mind " is built, and, in their absence, the brain cells 
ara probably incapable of producing a single idea. Sensation 
may be present without reason, but reason cannot exist with- 
out sensation. 

Although it is convenient to divide the total cerebral activity 
into three groups of processes — viz., sensory, mental, and motor 
— these are all interdependent. If the more purely psychological 
functions are defective, not only will outgoing currents be altered, 
but the accuracy and extent of sensations may be greatly inter- 
fered with. Attention in particular has a most important 
influence upon sensation, and many of the sensory defects of 
aments are due, not merely to defects of the sensory mechanism 
proper, but to imperfections of the higher neuronic activities 
of the brain. 

There are three elements concerned in sensation : a peripheral 
sense organ, a transmitting nerve, and a central receptive gan- 
glionic area. With regard to the nerve, beyond diminished size, 
I know of no structural differences between aments and normal 
persons. The peripheral sense organ is not infrequently the 
seat of disease or anomalies of development which may either 
completely cut off, or seriously interfere with, a particulai 
order of impressions ; but the chief cause of sensory imperfections 
in these persons lies in a defective condition of the central recep- 
tive ganglion cells or of the still higher perceptive mechanism. 

Sensation varies very much in aments, and on the whole is 
directly proportionate to the degree of mental deficiency. In 
the feeble-minded sensory defects are but slight, and consist 
chiefly of a diminished range and acuteness. In imbeciles more 
or less actual obtuseness of the senses is seen ; whilst in idiots 
this often reaches such an extreme degree that one or more of 
the senses seem to be actually wanting. 

7—2 



ioo Mental Deficiency 

Generally, apart from the presence of disease or congenital 
anomaly of a particular sense organ, the defect is uniformly 
incident upon all the senses ; but to this there are some remark- 
able exceptions, as will be seen in a subsequent chapter. 

Vision. — The chief peripheral defects have already been 
described ; they are strabismus, corneal ulcers and opacities, 
cataract, astigmatism, hypermetropia, and, less frequently, 
myopia. A few low-grade aments are congenitally blind, but 
colour-blindness does not appear to be commoner than in normal 
persons. These conditions, and, indeed, all anomalies of the 
end organs of special sense, are more frequent in the severer 
grades of mental deficiency. 

In the milder degrees of amentia visual defects consist chiefly 
in an inability to discriminate between the slighter differences 
of form, size, or colour. An octagonal will be confused with 
a hexagonal figure ; no difference will be noticed between the 
size of a florin and half-crown ; and, although these patients may 
differentiate between the primary colours, they are often unable 
to detect differences of shade. As we proceed down the scale of 
amentia, these defects become more marked, until in the severe 
forms of idiocy they exist to a very pronounced extent. The colour 
perception of the low-grade imbecile and idiot often seems limited 
to the recognition of red, and it is interesting to note that this 
is the colour which is usually most attractive to, and first recog- 
nized by, the normal child. The appreciation of form and size 
by idiots is very imperfect, and although they will distinguish 
between a child and a grown-up person, and between a man and 
a woman, many of them are incapable of any more delicate 
differentiation. Voisin states that in most imbeciles the per- 
ception of relief is wanting. 

Hearing. — Developmental anomalies of the external ear are 
very numerous, but it is very rarely that such interfere with 
hearing. Where there is a peripheral cause for deficiency of 
this sense, it is nearly always of inflammatory origin and situate 
in the middle ear. Otorrhcea occurs with considerable frequency 
in aments of all grades. 

Apart from cases of amentia due to sense deprivation, complete 
deafness is not common in the mentally defective. Some idiots 
and imbeciles will pay not the slightest regard to questions, to 



Nervous and Mental Characteristics of Amentia 101 

the sound of a whistle, or noises of many kinds, and they are 
on that account often thought to be deaf. That this is due to 
want of interest and attention, however, and not to deafness, is 
often shown by the fact that they will at once turn upon the rattle 
of a spoon and plate. Itard's wild boy of Aveyron was unre- 
sponsive to many sounds, and yet he showed a marvellous apti- 
tude for hearing those in which he was interested. In the 
feeble-minded grade of amentia there is not usually any marked 
deficiency of this sense, although hearing, as a rule, is neither so 
acute nor are the finer differences of tone so well detected as by 
the normal person. 

Taste. — In the milder aments there is not usually any 
marked impairment of this sense, although I doubt whether 
they have the delicacy of taste of an ordinary person. They 
have their likes and dislikes with regard to food, and they appre- 
ciate sweets and object to nasty medicines. In the more severe 
grades there is often an extreme defect of taste, whilst in many 
cases there is marked perversion of this sense. Thus, some 
idiots will munch sugar, quinine, or even soap, quite indifferently, 
and without the slightest indication that they distinguish one 
from the other. Others will eat and drink anything which comes 
within their reach, including wood, leather, grass, earth, stones, 
even urine and faecal matter or offal of the most putrid descrip- 
tion. 

One of the chief characteristics of the Mcngolian variety is a 
large fissured tongue, with hypertrophied papillae, but this does 
not appear to be accompanied by any particular anomaly of 
taste. 

Smell. — This sense is closely related to the preceding. In the 
milder aments ability to perceive odours is present, but is lacking 
in delicacy. In the more severe grades there often seems to 
be a complete absence of the sense. Many idiots will smell the 
most filthy compounds without the slightest sign of repugnance, 
and some will sniff strong ammonia without any reflex move- 
ment. In these latter a defective condition of the olfactory 
mucous membrane would appear to be present. 

Cutaneous and Muscle Sensibility. — The milder defectives 
can differentiate by the sense of touch between bodies which are 
hard or soft, rough or smooth, but they cannot appreciate the 



102 Mental Deficiency- 

finer gradations of these qualities so well as the normal child. 
The same remark applies to the sensation of pressure, as tested 
by weights or small pill-boxes filled with a varying number 
of coins or shot, and placed on the palm of the hand. In the 
imbeciles this sense of discrimination is still less acute ; but 
this may be apparent only, and due to the difficulty of examina- 
tion. In the idiots such a test is practically impossible. 

Alterations of temperature are certainly appreciated by the 
mild aments, but in many of the idiots this capacity seems to be 
wanting. They will sit in front of the hottest fire, under the 
most blazing sun, or exposed to the coldest wintry blast, without 
showing any concern. Pain is experienced by feeble-minded 
children ; they will complain of headache, toothache, or stomach- 
ache, but such sensations are often not so acute as in normal 
children, and many of the feeble-minded will suffer the extraction 
of teeth and other operations of minor surgery with relatively 
little concern. In the pronounced imbeciles, and more particu- 
larly in idiots, inability to feel pain is often a very marked 
characteristic. There are many idiots who will knock themselves 
against floor or walls, poke their fingers into their eyes, pull out 
their hair, teeth, or toe-nails, and injure themselves severely in 
many ways, without showing the slightest indication that the 
process is painful. I knew a boy some years ago who had such 
an incurable habit of sucking his fingers that the bone had been 
completely denuded of flesh, yet the practice seemed to afford 
him extreme pleasure rather than discomfort. It is practically 
impossible to make any experimental inquiries as to the condition 
of muscle, tendon, and joint sensations in these persons ; but, 
judging from their general clumsiness of manipulation, bodily 
balance, and movement, one is justified in assuming that such 
cannot be of a very high order. 

Organic Sensations. — The sexual instinct is by no means 
absent in the feeble-minded, also in many imbeciles, and even in 
some idiots ; indeed, in some of the milder degrees it is often 
inordinately developed. In the profound idiots such primitive 
organic sensations as those of hunger and thirst are wanting, 
and such persons would die of starvation if not fed. On the other 
hand, many of the partial idiots are extraordinarily gluttonous 
and voracious. In the lower types the painful sensations 



Nervous and Mental Characteristics of Amentia 103 

which accompany organic disease are often not appreciated, and 
these persons will be acutely ill, with pneumonia, gangrene of the 
lung, or tuberculosis, without making any complaint. In such 
cases there will be no subjective symptoms to guide the physician, 
and his diagnosis will have to depend entirely upon objective 
signs. 

Mental Processes. 

The essence of amentia is a defective development of the 
neurones which are the physical basis of the internal and 
more purely psychological functions ; these we have now to con- 
sider. In many cases disorders of sensation or motion are 
present as well ; but in the mildest examples these mental pro- 
cesses alone may suffer. In some instances we can even point 
to a special default of some one particular function, such as that 
of attention, imagination, memory, etc. ; but the mind cannot 
be thus divided into watertight compartments, and no particular 
defect can exist without disturbing the harmonious working or 
potentiality of the mind as a whole. 

Attention. — The act of attention consists in the focussing of con- 
sciousness upon an idea or the mental image of an object, to the 
exclusion of other ideas. It may be spontaneous and involuntary 
or active and voluntary, and it is necessary to consider these 
separately. 

Spontaneous attention occurs when a sensation or idea is so 
sudden, so intense, or so unusual, that it holds consciousness 
renexly and without any mental effort. Of this nature is the 
flash of lightning, the peal of thunder, or any sight or other sensa- 
tion to which the beholder is utterly unaccustomed. This form 
of attention is characteristic of children and the lower animals, 
and although, of course, dependent upon the nature of the 
stimulus, variations in it are more influenced by the condition of 
the cerebral cells with regard to their inherent excitability. It 
may be compared to the violent shock inflicted upon the cerebral 
mass of the child of a few weeks old by any sudden noise, and 
which results in a general start of the whole body ; with the 
development of consciousness this general bodily change is often 
still seen when attention is involuntarily aroused. 

In the lowest type of idiocy feeling is very rudimentary, and 
hence even this spontaneous form of attention is defective. 



104 Mental Deficiency 

But even where perception is present the cerebral excitability 
may be so diminished as to bring about a considerable deficiency 
of spontaneous attention, and this is the case with many idiots 
and imbeciles as well as with a few feeble-minded. Such persons 
are dull and lethargic ; they seem to be utterly unconcerned by 
anything happening around them, and they have no curiosity 
or initiative. If in school, they sit at their desks gazing vacantly 
in front of them ; if in the playground, they stand aloof in a corner, 
without the slightest desire to take part in the games of their 
companions. They respond tardily, or not at all, when addressed, 
are stolidly indifferent when interfered with, and are, in fact, 
so generally inert as to give rise to the impression that they are 
deaf. But there is no real sensory defect, and the condition is 
simply one of general brain inertia. By appropriate methods 
of training, the excitability of the brain cells may often be in- 
creased and the child aroused out of his lethargy. 

Active or voluntary attention takes place when the idea or sensa- 
tion attended to has no compelling power of its own. Attention 
to it may, indeed, be distasteful, and the focussing of consciousness 
upon it, so that other ideas and impressions are for the time being 
shut out, demands a very considerable voluntary effort. It is 
plain that attention of this kind is indispensable to the acquire- 
ment of knowledge and the conduct of human affairs, and the 
person in whom it is greatly lacking will cut but a sorry figure in 
life. 

This is the case with a large number of aments. They are 
quite incapable of concentrating their thoughts upon a particular 
subject, and they consequently have no power for sustained 
work. It follows that their education and training is exceedingly 
difficult. Persons of this type differ from those lacking in spon- 
taneous attention in several noteworthy points. Instead of 
being heavy and lethargic, they are often active and restless, and 
attracted, but distracted, by every sight and sound around them. 
The condition is thus the exact opposite of the former type, and 
at first sight would appear to result from an excessive, instead of 
diminished, nervous excitability. This, however, is by no means 
necessarily the case, and very often the fault seems to lie rather 
in a defective power of co-ordination and control. It is often 
associated with the presence of tricks and habits. As Maudsley 



Nervous and Mental Characteristics of Amentia 105 

says, " The person who is unable to control his own muscles is 
incapable of attention." 

This condition of imperfect muscular control and defective 
attention is, of course, characteristic of normal infancy ; but 
whereas it is but a phase in the development of the healthy child, 
it is a much more persistent, and often permanent, condition in 
the mentally defective. It is undoubtedly responsible for much 
of the faulty perception and discrimination of these persons, 
and, since our stock of ideas is dependent upon the multi- 
plicity and accuracy of sensations from the outer world, some 
would see in this defective power of attention the psychological 
fons et origo of mental deficiency. But, whilst admitting to this 
faculty a most important share in the quantity and quality of 
the intellectual processes, its lack in these persons is not sufficient 
to account for their imperfect reason and want of common sense. 
Moreover, there are many aments in whom attention is not 
lacking. We must therefore consider the defective attention of 
aments, not as the prime cause, but as only one factor of that 
general imperfection of mental faculty which constitutes amentia. 

Association and Memory. — If a healthy, intelligent child of 
between three and four years be asked to describe, from memory, 
some common object — such, for instance, as a cat, a chair, or 
table — and if a little direction be given to his thoughts by not 
too leading questions, a very good estimate will be formed as to 
his capacity of memory and association. To those unacquainted 
with the mind of an intelligent child of this age the result is 
often surprising, and contrasts in an extremely marked manner 
with a similar examination of the mentally defective child of 
much greater age. I have often found the mental images in a 
defective child of twelve or even fourteen years to be far simpler, 
and to have only a fraction of the associations which are present 
in the former case. In the lower aments the deficiency is still 
more marked, although such an examination in their case 
is extremely difficult. We may therefore say that aments 
generally are decidedly inferior in the power of association and 
recall. 

No doubt much of this is due to a faulty perception, which 
in its turn may be the result of a defective attention and in- 
capacity for mental effort ; and although, as we have seen in 



106 Mental Deficiency 

speaking of pathology, one of the distinguishing features of the 
anient 's brain is a paucity of association fibres, it is a moot point 
whether this is a primary deficiency or a secondary result of their 
faulty perception. 

But although there is a diminished complexity of association, 
the connexions which do exist seem to cling together with a very 
considerable, and at times even extraordinary, tenacity. This 
is shown in the remarkable powers of some aments for repeating 
poetry, remembering dates and names, and other similar feats 
of memory. Such instances are, of course, exceptional ; but in 
many aments the general tenacity of memory for striking events 
and certain isolated occurrences which have appealed to them 
does not seem to be markedly inferior to that of the normal 
person. In their general power of recall, however, and in their 
ability to remember ordinary things and the little occurrences of 
everyday life, there is, as a rule, a decided defect. 

Imagination. — Fantasy, reverie, and day-dreaming occur in 
some of the milder aments, although in a much simpler form 
than in the normal person. Moreover, many of those of unstable 
type have delusions without either mental exaltation or depres- 
sion. A few are even capable of a certain amount of constructive 
imagination, as is shown by their skill in drawing and mechanical 
invention, as well as by the cunning with which they commit 
thefts and the ingenuity with which they invent plausible lies 
to screen themselves and incriminate their companions. On the 
whole, however, there seems to be a decided defect in the faculty 
of imagination in aments. The higher types may copy a drawing 
or design ; they may produce faithful models of flowers or fruit ; 
they may, indeed, have a very high degree of manipulative skill ; 
but their work is generally a slavish imitation, and they hardly 
ever originate. And when they do, the result is not usually 
creditable to their imagination. If mentally defective school- 
children be watched drawing, brick-building, or pattern-making, 
it will generally be found that they follow the same stereotyped 
plan, and that they do not evince a fraction of the originality 
shown by the normal child. In the imbeciles and idiots the 
deficiency is much more pronounced. 

Ideation. — In view of their defects of attention, perception, 
and memory, it necessarily follows that the capacity of aments 



Nervous and Mental Characteristics of Amentia 107 

for forming ideas is limited, and conversation readily reveals the 
general crudity and childishness of their thoughts. One may, 
indeed, say that the intellectual life of these persons consists 
almost entirely of perceptions, and not conceptions — that is, of 
simple ideas relating to objects which are immediately present 
to their senses. I cannot agree, however, with the statement so 
often made, that the ament is utterly wanting in the capacity 
for forming abstract ideas. It is true that the concrete is much 
more readily grasped than the abstract, and it is interesting to 
note that many feeble-minded school-children find it much easier 
to express their ideas by means of a drawing than by a word ; but 
there is no doubt that many of the milder grade are quite capable 
of conceiving such universals as mankind and womankind, 
goodness and badness, and the like. Of abstracting in the logical 
sense, however, most of them are probably quite incapable. 

Judgment and Reasoning. — To reason is to think, but thinking 
is not reasoning. Most of our thinking consists simply of a 
review of mental images which successively rise into consciousness 
in accordance with the laws governing association. The thought 
which is past has suggested that now present, and this in its turn 
suggests that to come, the series depending upon previous 
experience (perceptions) and the type of our mental constitution. 
Thinking is thus to a great extent a form of reverie, although 
thoughts may be directed and confined to a certain channel by 
an effort of will. 

Reasoning, on the other hand, is not only a definite and 
deliberate effort of volition, but it also involves other processes 
which are not concerned in mere thinking. Without attempting 
to discuss what these are, or the manner of their working, it 
may be said, briefly, that reasoning consists in, firstly, the 
deliberate contemplation of certain ideas ; the abstraction from 
these of their essential attributes ; the comparison of these ab- 
stractions ; and, finally, the construction of an idea or judgment 
which is new to our mental experience. 

Reasoning thus involves activities of a higher order than any 
hitherto considered, and the chief characteristic of amentia is 
a defect of these functions. This defect reaches its maximum 
in the most pronounced degree of amentia, and in the majority 
of idiots the ability to reason may be said to be completely 



io8 Mental Deficiency 

absent. The absolute idiots would even die of starvation, in 
the midst of food, if they were not fed. The feeble-minded, on 
the other hand, are by no means destitute of this faculty ; for 
instance, if a mentally defective child, who is ignorant of money 
values, be offered the choice of a shilling or half-crown, he may 
choose the latter " because it is bigger." 

Upon asking a feeble-minded adult, whose daily work con- 
sisted in cleaning the type in the printing-room, what he was 
cleaning it with, he said, " Turps." Upon then asking him what 
he washed his hands with, he replied, " Soap and water." But 
he was for a time quite nonplussed when asked why " turps '' 
wouldn't do for his hands, or " soap and water " for the type. 
At length, however, after much floundering, I got out of him 
that soap and water wouldn't get the ink off the type, and that 
turpentine would make his hands sore. Nevertheless, although 
these persons possess some power of reasoning, it is so limited 
that they are quite unable to steer a course upon life's sea, or 
even to keep their heads above water, without support. 

The imbeciles, as a class, are intermediate between these two 
extremes. I sent a feeble-minded and an imbecile youth respec- 
tively to fetch an article out of a room, the door of which had 
been locked and the key hung up in a conspicuous place above 
the handle. The feeble-minded one went to the door, tried the 
handle, found it locked, seemed nonplussed for a moment, «then 
saw and took down the key, opened the door, and performed his 
task. The imbecile tried the door, gazed vacantly at the key, 
turned round, and said, " Locked." Upon being asked where 
the key was, he pointed, and said, " There," but when again told 
what to fetch he made no effort to use the key. Upon my placing 
the key in the lock, he turned it, opened the door, and got the 
desired article. A somewhat similar test was tried between two 
other children. It was a pouring wet day, and I placed an 
umbrella near the door, and told them to fetch a certain flower 
out of the garden. The feeble-minded child opened the door, 
saw the rain coming down in torrents, and, after a pause, picked 
up and opened the umbrella. The imbecile would have got wet 
through had he not been called back, but, when given the um- 
brella, had enough sense to open it before going out. 

Temperament. — Temperament is dependent upon physiological 



Nervous and Mental Characteristics of Amentia 109 

peculiarities of nerve action, and the mentally defective person 
is just as subject to differences in this respect as is the normal. 

Since the days of Aristotle it has been customary to describe 
four temperaments — namely : 

Choleric, where the excitability is great and after-effect great. 
Sanguine, where the excitability is great and after-effect 

small. 
Phlegmatic, where the excitability is small and after-effect 

small. 
Melancholic, where the excitability is small and after-effect 

great. 

I cannot recall an ament who could rightly be described as 
choleric ; most are of the phlegmatic type, some are sanguine, 
and a few — chiefly of the mildest grade — are melancholic. 

Although most aments will display a childish, and at times 
keen, interest in spectacular displays, they are not, as a rule, 
aroused thereby to the same pitch of enthusiasm as a normal child. 
Moreover, the impression quickly fades, and they soon cease to talk 
about it. Although by no means insensible to praise or blame, 
pleasure or punishment, they are not, as a rule, greatly affected 
thereby, and the sensation is but fleeting. Some of the milder 
grades, it is true, evince a considerable amount of mental perturba- 
tion on first leaving their friends for the care of strangers ; but 
they are seldom really home-sick, as is the ordinary child, and they 
rapidly settle down to their new surroundings with hardly a 
thought of the old. Of most of them it may be said that their 
general attitude is one of placid indifference, and that they are 
decidedly less affected by the happenings of life than are ordinary 
people. 

A few may be described as sanguine. They are quick, lively, 
and readily attracted by anything happening around them, and 
easily moved to laughter or tears, passionate anger, or cloudy 
sullenness. But this state is very fleeting, and leads to little 
result. Though seemingly full of interest in everything, they 
settle down to nothing. 

Another small proportion belong to the melancholic type. 
In these, although censure, punishment, or neglect seem to make 
little impression at the time, the child or adult becomes morose, 



iio Mental Deficiency 

and begins to brood over his real or fancied wrongs. Sometimes 
a state of true melancholia results, and I have known several 
persons of this type who have attempted suicide. 

Emotion and Sentiment. — The emotions most commonly seen 
in aments are the simple ones of pleasure, grief, affection, anger, 
fear, and surprise. The more complex states of shame, awe, 
contempt, disgust, indignation, hate, and jealousy, are compara- 
tively rare and of little intensity. On the whole, the capacity for 
experiencing emotion seems to be directly proportionate to the 
amount of general intelligence present, although much depends 
upon the particular variety of nervous temperament. In the 
absolute idiots emotion is lacking altogether. 

Moral Sense is lacking in the lowest grade of amentia, and in 
the imbeciles and feeble-minded it rarely reaches a high degree 
of development. Most of these persons act upon the impulse 
of the moment, quite unaffected by any altruistic feelings. They 
may develop the habit of refraining from lying or pilfering 
because they realize that such lead to punishment ; but the 
majority do not understand that any obligation is morally due 
from them, or that they should be virtuous for virtue's sake. 
On the other hand, a few do acquire rudimentary notions of un- 
selfishness and good behaviour, and some, even, are capable of 
hazy anthropomorphic ideas of a Superior Being, thus showing 
the germs of a religious sense. They may be taught, and in a 
simple way understand, the Bible stories ; they may tell one that 
after death the good people go to heaven and the bad ones to 
hell, and this belief may be not without effect upon their daily 
behaviour ; but of theological dogma or doctrine beyond this 
the majority have little conception. 

Finally, as a connecting link between mental and the more 
obvious motor phenomena to be next described, we may refer 
to the subject of Will. Volition, although frequently leading 
to action, is not to be confounded therewith ; in fact, in its 
highest form it is probably more often associated with the 
inhibition rather than the initiation of movement. Conse- 
quently the restless activity and the sudden impulsive acts of 
feeble-minded children are by no means an indication of will 
power, but rather the reverse. Will is always accompanied by 
mental effort, and of this, to any great extent, the mentally defi- 



Nervous and Mental Characteristics of Amentia 1 1 1 

cient are often incapable. Their inability to keep an ideal or 
course of action steadfastly in front of them leads to the absence 
of fixity of purpose or capacity to offer serious resistance to the 
will of others. Consequently many of them readily fall in with 
suggestions which are made to them, and easily become the prey 
and tools of designing and evil-disposed persons. 



Motor Processes. 

Mind is manifested as motion, and mental and motor activities 
run on parallel lines. The motor functions of the body, as seen 
in movement and speech, are generally similar in quantity and 
quality to the more purely psychological processes just described, 
and, since they are capable of more ready investigation, they often 
afford valuable indications as to the nature and working of the 
mind. This relationship has been ably pointed out by Dr. 
Francis Warner,* and to this author we are indebted for much 
valuable information regarding anomalies of motor function, 
or, as he terms them, " abnormal nerve signs," in the mentally 
defective. 

Movement. — The simplest form of movement is, in all prob- 
ability, the result of explosions within the motor ganglion cells 
taking place in consequence of their own inherent instability. 
Such movement is spontaneous, and is seen in the spreading 
of the fingers and toes of the young infant (the " microkinesis " 
of Warner) , later in the inarticulate babblings which denote the 
first activity of the motor cells concerned in speech. Presently, 
as a result of the laying down of pathways within the cerebral 
mass, the motor cells require two connexions. One of these 
brings them into relation with the sensory areas of the brain, 
the other with the higher levels concerned in ideation and 
volition. As a result of the former of these connexions, the 
simple spontaneous movements become so modified and con- 
trolled by the quantity and quality of the incoming sensations 
as to be perfectly adapted to them. We then have a co-ordinated 
movement, in which an optimum result takes place with a 
minimum expenditure. When this result has been attained, and 

* Francis Warner, "Anatomy of Movement," "Mental Faculty," and 
numerous other writings. 



ii2 Mental Deficiency 

a well-worn pathwa}^ established between sensory and motor 
areas, the appropriate movement is readily called forth upon 
the presentment of its customary stimulus, producing a reflex 
co-ordinated action. 

The new-born child comes into the world with some of these 
channels already laid down, so that it is capable of so-called 
instinctive or hereditary movements, such as sucking and crying. 
Many of the ordinary reflex movements are the result of spinal 
rather than cerebral action. 

The second connexion, w T hich links up the motor cells with those 
portions of the brain concerned with the intellectual processes, 
brings the motor functions under the influence of the will, and so 
makes volitional action possible. Such action is always pre- 
ceded by an idea of the motion to be performed (motor idea). 
The nature of this volitional action, however, will be different 
according as other intellectual associations act as a drag or not 
upon immediate response. In the simplest and lowest type of 
mind an immediate response follows the presentment of the 
idea, and the action is impulsive. Such may take place 
almost with the rapidity of a reflex act ; indeed, by constant 
repetition the motor idea to an action of this kind may be sub- 
conscious, and the action truly reflex. On the other hand, the 
motor idea may call up other associates, so that deliberation 
intervenes to delay or inhibit the natural tendency to immediate 
action. After a longer or shorter period of deliberation, in which 
the pros and cons are carefully passed in review, a choice is 
made, and finally the highest type of action — a deliberate, pur- 
poseful manifestation of will — results. 

We thus see that in aments various anomalies of movement 
may occur as a result of their imperfection of development. The 
metabolism or excitability of the motor ganglion cells may be 
abnormal, and the quantity of movement defective or excessive. 
Sensations may be imperfect or distorted, or the connexions 
between sensory and motor areas faulty, leading to defects in the 
quality of movement or inco-ordination. The connexions be- 
tween sensory and motor centres which are normally laid down 
at birth may be lacking, producing a diminution or absence of 
the instinctive movements — a condition which is by no means 
infrequent in idiocy. On the volitional side response may occur 



Nervous and Mental Characteristics of Amentia 1 1 3 

immediately upon presentment of the idea, and impulsive action 
of this kind is very characteristic of many aments. On the 
other hand, response may be tardy, not because of the inter- 
vention of deliberation, but because the cerebral cells generally 
are lethargic and unexcitable, and the connexion between voli- 
tional and motor centres a comparatively untrodden pathway ; 
and this kind of slothful action is characteristic of another type 
of aments. Finally, anomalies of movement may occur in 
consequence of gross lesions or disease of the cerebro-spinal axis. 
We may now consider the chief of these anomalies of the motor 
functions somewhat more in detail. 

Deficient Movement. — In a considerable number of aments 
movement is deficient in quantity, and this is the result of a 
generally diminished excitability of the nerve cells. The con- 
dition is most common in the severest grade, but it is also seen 
in the imbeciles and feeble-minded. In the most pronounced 
cases it is obvious from birth, and the child never cries, sucks, 
or looks about him like an ordinary child ; in the milder forms 
these instinctive movements are present, but the child is back- 
ward in his first attempts at sitting up, standing, and walking, 
whilst speech is very much delayed. The appearance of such 
children is usually characteristic ; the face wears a dull," heavy, 
vacuous expression, and there are many indications of want of 
muscular tone. In the temporal and masseter muscles this 
often shows itself by dropping of the lower jaw and a persistently 
open mouth. The general balance of the body is feeble, and when 
the child walks, he does so with a slothful clumsiness. If told 
to follow an object with his eyes, he either makes no response 
or turns his whole head round in a slow and laboured manner. 
His arms are listlessly extended to command, but the fingers 
and hands hang flabbily down, and the whole arm very soon 
drops to the side. His whole appearance and behaviour are 
indicative of cerebral and spinal inertia. 

Excessive Movement. — In another type of aments all movement 
is in excess, and the condition is one of chattering, ceaseless 
activity. This also is noticeable soon after birth, and the 
remark is often made by the parents that the child " never 
sleeps." This, of course, is not really the case ; for although 
these children do not have regular long periods of sleep like 

8 



114 Mental Deficiency 

ordinary children, or even ordinary idiots, there is no doubt 
that they do have brief but frequent snatches. There is equally 
no doubt, however, that their sleep is very light and readilv 
disturbed. This condition is the antithesis of the one just 
described, and is due to hyper-excitability of nervous tissue. 
For some time after birth it is manifested as an excess of spon- 
taneous movement, but, as the motor cells acquire connexions 
with sensory and ideational areas, this type of movement alters, 
being replaced by actions of a higher order. Of these there are 
three chief forms — namely, ideo-motor repetitive actions of sub- 
conscious type ; ideo-motor repetitive actions of conscious type ; 
and impulsive volitional actions. It is to be remarked that, 
although these varieties of excessive movement are very common 
in amentia, they are not characteristic of that condition, but may 
occur in a merely neurotic child. Most of these forms of excessive 
movement are accompanied by a diminished capacity for sus- 
tained attention, and this is well seen in the restless ament whose 
attention is so distracted by every sight, sound, or feeling reach- 
ing his sensorium that steady continuous work becomes an 
impossibility. 

In a considerable number of aments excessive action is chiefly 
pronounced in certain groups of muscles, and, by being constantly 
repeated, the movements acquire an automatic and subconscious 
character. They are then popularly known as tricks or 
habits. The most frequent of these are spasmodic frowning 
and knitting of the eyebrows (which may be symmetrical or 
unilateral), grinning, smiling, and grimacing; nodding and 
shaking of the head ; shrugging of one or both shoulders ; open- 
ing and shutting of the hands, and swaying of the body ; biting 
the nails, sucking the thumb, and many others of like character. 
The characteristic of these movements is that, at first irregular, 
they subsequently tend to be repeated at more or less regular 
intervals, and are particularly marked when the child is in the 
presence of strangers and conscious that he is being observed ; 
further, unlike the irregular, purposeless movements of chorea, 
they are definite co-ordinated acts. Originally it is probable 
that many of them had a purpose ; for instance, I have some- 
times traced the repeated shaking of the head, which is very 
commonly seen in neurotic children, to the presence of long, 



Nervous and Mental Characteristics of Amentia 1 15 

straggling hair hanging in front of the eyes. The frequent repeti- 
tion of the act produces in time a kind of obsession, and this leads 
to its automatic unconscious performance when the original 
cause has been removed. In aments it often lasts throughout 
life. 

Closely related to these automatic actions are others of a 
somewhat higher character, inasmuch as they are always volun- 
tarily performed. Dr. John Thomson* enumerates the chief 
of these as pica, or dirt-eating, sucking the tongue, thumb, etc., 
biting the nails, head-rolling, head-banging, rocking and swaying 
movements of the body, and masturbation. Dr. Thomson says 
that " the normal act causes little pleasure to the healthy child, 
whilst its morbid counterpart has an extraordinary fascination for 
the children who practise it. . . . The essential character which 
serves at once to distinguish these habits from certain motor 
neuroses (e.g., spasmus nutans and habit spasm), which some of 
them superficially resemble, is their deliberateness. The child's 
will is implicated ; and what he does is done intentionally — at 
first, at least — because he likes doing it. They have a strong 
tendency to occur when the patient is feeling dull and not being 
interested by his surroundings. They are almost always stopped 
when the child's attention is taken up with anything that 
interests him." 

Finally, another type of excessive movement is seen in the 
impulsive volitional actions which are of such frequent occurrence 
in certain mental defectives. With these persons, an idea is no 
sooner presented than it is acted upon, quite regardless of right 
or wrong or possible consequences. Many of them belong to 
the milder degrees of amentia, and some are by no means un- 
intelligent ; but their whole life is actuated, not by intelligence, 
but by impulse. The essential basis seems to be an undue 
motor excitability, and the defective deliberation and control 
allow this to have free play. They comprise the " unstable " 
type of aments, of whom more will be said in subsequent chapters. 

Inco-ordinate Movement. — Co-ordination, in the wide mean- 
ing of the term, requires a series of motor explosions which are 
regular in time, degree, and sequence, as well as their harmonious 

* John Thomson, "On Certain So-called 'Bad Habits' in Children," 
Archives of Pediatrics, April, 1907. 



1 1 6 Mental Deficiency 

adaptation to the various sensory stimuli concerned in the move- 
ment performed, particularly those coming from the muscles. 
It is therefore dependent upon perfectly working sensory, com- 
missural, and motor mechanisms ; but even where these exist, 
as in the normal child, perfect co-ordination is only attained by 
constant practice. 

In persons suffering from even the mildest degree of amentia, 
co-ordination is often acquired with difficulty, and remains im- 
perfect ; and although many of them may learn to use their 
hands with a considerable amount of dexterity, the balance and 
movement of the body often continue clumsy and ungainly. 
It is frequently years before the mentally defective child manages 
to lace his boots, button his clothes, or manipulate his spoon at 
table. Even the best of them (with a few remarkable exceptions) 
rarely attain to the precision and neatness of movement of which 
an ordinary well-trained child is capable. 

In the lower degrees the defect is still more marked, and many 
imbeciles experience the greatest difficulty in picking up a pin 
or a coin, and are incapable of any but the coarsest movements. 
Ireland remarks that considerably more imbeciles than normal 
people are ambidextrous ; but I think it is not that both hands 
are used equally well, but rather equally badly, and I should 
prefer to say that they were adextrous. Many of their defects 
of speech are due to imperfect muscular co-ordination. 

An extremely delicate test of the degree of control over mus- 
cular action is afforded by the " transfer " and " imitation " 
movements of Dr. Warner. In performing imitation movements, 
the child stands a little distance in front of the observer, who 
performs a series of extensions, flexions, and other movements 
with his own arm, forearm, hand, and finally individual digits, 
each of which the child must imitate as it is performed. In 
the transfer movements the child stands with closed eyes and 
extended hands. The observer then performs passive movements 
upon the digits, etc., of one limb of the child, who is required to 
make corresponding movements with the other. Dr. Warner tells 
me that he considers these tests to be extremely delicate, and 
that even in a healthy person slight imperfections may be 
observed as the result of fatigue. 

Finally, it may be remarked that anomalies of movement 



Nervous and Mental Characteristics of Amentia 1 17 

due to localized or general disease of the brain are not uncommon 
in aments. The chief of these are nystagmus, athetosis, epilepti- 
form and epileptic convulsions, and chorea ; but they do not differ 
from similar affections in the mentally sound. 



Speech. 

The speech of aments is a matter of considerable interest and 
importance, for several reasons. In the first place, defects of 
speech are very frequent, and their examination affords a means 
by which certain sensory, associative, and motor functions may 
be conveniently tested and recorded. Further, quite apart from 
its mere mechanism, the language of these persons is one of the 
most valuable means we have of gauging their stock of ideas and 
the general capacity and nature of their intellects ; whilst in the 
milder degrees the training of speech, if conducted upon scientific 
principles, and after a careful study of the needs of the individual, 
is a very important means of improving sensory and motor 
functions, and regulating mental action generally. 

True speech is not merely the ability to utter articulate sounds : 
it is the faculty of using words to express thoughts ; and before 
this can take place certain conditions must be fulfilled. These 
are, firstly, the power to hear sounds ; secondly, a conscious 
recognition of the object or idea for which the sound heard 
is the symbol ; thirdly, an ability to reproduce the sound 
as the expression of the same object or idea. It is thus seen 
that the faculty of speech is composed of an afferent pathway 
(normally auditory, although exceptionally other sensory channels 
may serve instead, as in lip reading), with its prolongation to a 
higher conscious station ; of a connexion between this conscious 
station and the motor speech centre ; and thence an efferent path- 
way to the muscles concerned in phonation and articulation. In 
addition, there is good reason for thinking that a more direct 
and subconscious connexion exists between the sensory and motor 
centres. The nervous mechanism concerned in speech may 
therefore be represented by the capital letter A, in which the 
side-limbs denote the afferent and efferent paths respectively to 
and from consciousness, and the cross-piece the shorter sub- 
conscious connexion between the sensory and motor stations. 



1 1 8 Mental Deficiency 

In the normal child sounds are differentiated in the early 
months of life, but it is not until he is nearly a year old that he 
begins to associate words with objects and ideas, and to under- 
stand what is said to him. At this age he has still little command 
over the motor speech centre, the first evidence of activity in 
which consists of cooing and babbling interjections of spon- 
taneous origin similar to the incessant small movements of fingers 
and toes. Presently, however, owing to the faculty of imitation, 
these irregular sounds become co-ordinated into copies of those 
he hears, and very soon after this the child acquires the power 
of expressing his simple thoughts and wants by articulate speech. 
After this progress is usually rapid, and during the third year 
the child may possess a vocabulary of several hundred words. 

In the ament defects of speech are exceedingly common, 
probably being present to some extent in fully three-quarters 
of all cases. In these persons the advent of speech is nearly 
always delayed, the first indication of spontaneity in the 
motor cells, which normally appears during the third or fourth 
month, not being noticed until much later. It may be five, 
six, or even more years before the mentally deficient child gives 
utterance to a definite word as the expression of an idea. In 
the severest grades of mental defect the faculty is never de- 
veloped, and the majority of idiots are incapable of articulating 
a single word. Others of this degree can say a few mono- 
syllables, such as " man," " cat," but none of them are capable 
of forming sentences. In the imbecile speech is usually present, 
and he is able to understand and speak short sentences ; but his 
vocabulary is small, and his utterance often almost unintelligible. 
In the feeble-minded degree, imperfections of utterance tend to be 
somewhat less, and the vocabulary considerably more extensive ; 
but these persons are usually neither capable of forming nor 
understanding a sentence at all complicated in its construction. 

It is thus seen that on the whole there is a tolerably close 
relationship between the capacity for speech and the degree of 
mental defect, and this led Esquirol to suggest the use of this 
faculty as a means of classification. But to this there are many 
exceptions : some quite low-grade imbeciles are possessed of 
exceedingly good articulation and fluent speech, whilst a small 
number of the feeble-minded are limited in their utterance to a 



Nervous and Mental Characteristics of Amentia 1 19 

few words, and even these may be almost unintelligible. The 
remarkable genius of Earlswood Asylum, of whom a description 
will be given in a subsequent chapter, is an excellent example 
of this latter class. It is true that those imbeciles whose speech 
is so fluent often have little or even no idea of the meaning of 
the poetry or sentences they so glibly repeat, and it is quite open 
to question whether their articulatory capacity properly comes 
within the strict meaning of the term " speech." But, even 
apart from this, I am of opinion that there is no such constant 
relationship between wealth of ideas and capacity of expressing 
them as would justify us in accepting speech as a means of differ- 
entiation ; and the physician must be upon his guard against 
judging of the degree of mental deficiency by the amount of 
speech. 

In cases where there is no deafness, and speech is markedly 
deficient, it is highly probable that some degree of defect is 
present, and delayed speech is often one of the first signs to 
attract the parents' attention, and causes professional advice to 
be sought ; but, as an indication of the amount of defect, expres- 
sion and general behaviour may be of far more importance than 
speech. 

Defects of speech may be due to anomalies of the sensory, 
motor, or intellectual (association) pathways ; but in most 
caseo it is the two latter which are chiefly at fault. Sensory 
defects may be auditory, causing an imperfect perception of 
sounds ; or they may concern the tactile and muscular sensations 
coming from the tongue and lips during the act of articulation. 
It has already been remarked that the range and delicacy of the 
sensorium of the ament is often diminished, and in a few more 
or less actual deafness is present. I do not think, however, that 
imperfections of hearing play a very important part in the 
defective speech of these persons. 

Anomalies of the motor mechanism are much more frequent, 
and these comprise imperfections of the cortical speech centre, 
or of the end organs concerned in the production of voice and 
speech. With regard to central defects, pure motor aphasia is 
rare ; but one boy, who was under my care for several years, 
was a perfect example of this condition. In this case there was 
at times considerable inattention ; but the boy had no loss of 



120 Mental Deficiency 

hearing, and could understand and obey commands perfectly 
well. He could also make grunting and other inarticulate 
noises, but the only approach to a word which we could get him 
to say after years of training was " Cuckoo. " This case, however, 
was one of secondary and not primary amentia, and resulted from 
an attack of encephalitis in the early months of life. Another 
and much more common cortical anomaly is the want of 
co-ordination which results in stuttering and stammering. 
Peripheral deficiencies are exceedingly numerous, and the whole 
character of the voice and speech may be profoundly altered by 
deformities of the tongue, lips, teeth, and palate, as well as by 
enlarged tonsils and adenoids. I doubt, however, whether short- 
ness of the fraenum linguae (" tongue-tied ") can ever be con- 
sidered a cause of delayed or even imperfect utterance. 

Defects of pronunciation are exceedingly common in even the 
mildest grades of amentia, and are generally attributable to im- 
perfect co-ordination. It is not usual to find any marked impair- 
ment of the vowel sounds, the chief imperfections being noticed in 
the consonants (" lalling "). The physiological alphabet of Wyllie* 
forms the basis upon which many interesting observations have 
been made in recent years, amongst which those of Dr. Henry 
Ashbyf and Dr. LapageJ deserve particular mention. To this 
latter inquirer we are indebted for a most careful research into 
the consonantal defects of the feeble-minded child, and the 
following table is to a great extent compiled from his work. 
In this table the consonants are placed in the order in which 
Dr. Lapage found them most frequently defective, the sounds 
commonly substituted being also shown (see Table XIII.). 

It is of interest to compare this defective power of pronuncia- 
tion, which is so common in aments, with the marked aptitudes 
in this respect of some of the lowest savages. Darwin, in his 
" Voyage of the Beagle" relates that the Fuegians " could 
repeat with perfect correctness each word in any sentence we 
addressed to them, and they remembered such words for some 
time. . . . All savages appear to possess, to an uncommon 
degree, this power of mimicry. I was told of the same ludicrous 
habit among the Caffres ; the Australians, likewise, have long 

* Wyllie, " Disorders of Speech," 1904. 

t Ashby, " Speech Defects in Mentally Deficient Children," Medical 
Chronicle, October, 1903. 
% Lapage, op. cit. 



Nervous and Mental Characteristics of Amentia 121 



been notorious for being able to imitate and describe the gait of 
any man, so that he may be recognized." As will be seen 
in speaking of idiots savants, such extraordinary powers are occa- 
sionally present in aments ; but they are the exception, and not 
the rule. 

The disorders of speech which are chiefly due to commissural 
and intellectual defects include the misapplication of words and 
the inability to recall appropriate words ; whilst it is only to be 
expected that where ideas are few the vocabulary will not be 

TABLE XIII. 

Consonantal Defects. 





Consonant. 


Commonly 
replaced by 


As in 






' 1. 


Th 


F or T 


Fumb, tee/, raou/, /ank. 






2 . 


R 


Y or L 


Yabbit or /abbit, pa/Jot. 






3- 


Y 


R or L 


Lellow. 


Most 




4- 


S 


T or Ts 


Tissors, /soap. 


frequently 
defective 


« 


5- 
6. 


G 
Ng 

Sh 


I) 
D 
Tsh or T 


Dun, dod, sudax. 

String. 

Tsheep, Tshudar, Tirt. 






8." 


K 


T 


Tat, /oat, bla/. 






9- 


V 


B 


Velvet. 






10. 


L 


Y 


Yeg, yad. 






( "' 


F 


T 


To//ee. 






12. 


Z 


Dse 


Nodse. 






*3- 


W 


M (or 


M indow . 


Less 








omitted) 




frequently 
defective 


- 


14. 

is- 
16. 


P 
N 
D 


T or D 

D 

T 


Darfer. 

Tose, Ped, Peddy. 

Toor, la/. 






I/- 


T 


D 


Deef. 






18. 


M 


B 


Ja6. 






1 19- 


B 


P 


Pag. 



extensive. The enunciation of the grown-up ament often retains 
much of the character of childhood, whilst a general brain inertia 
(sometimes, however, a timidity under examination) causes speech 
to be slurred, hesitating, indistinct, and at times almost unin- 
telligible. As Max Muller remarks, correct and distinct speech 
requires a definite mental effort, and of this many aments are 
incapable. 

In some aments the condition known as coprolaljji, or 
" filthy speech," exists. This is a more or less sudden outburst 
of language of the most vile and disgusting character, and it is 



122 Mental Defici 



ency 



remarkable that it often occurs in persons brought up amid 
every refinement. It is usually accompanied by a general state 
of mental excitement, for which, however, no cause may be dis- 
coverable, and it has considerable analogy to the motor convul- 
sions of the epileptic. It is also common in the insane. 

Finally, mention must be made of that curious speech dis- 
turbance known as echolalia, In this condition, although the 
child can, and often does, use words to express his ideas, any 
question put to him is followed, not by a reply, but by its repeti- 
tion. Sometimes, after repeating the question once or twice, 
the child will answer it ; but in other cases he is merely repetitive, 
and often copies the tone and manner of the questioner with 
remarkable exactitude. I recently saw a mentally defective 
child with this peculiarity, whose parents assured me he could 
speak quite sensibly, and yet to my questions the only words 
I could get out of him were, " What is your name ?" " Who is 
this ?" (pointing to his mother), " Shut the door," and similar 
repetitions of every question or command. This condition is 
not very common, and is somewhat difficult to explain. I am 
disposed to think that it may be due to the child's consciousness 
being so swamped or occupied (by emotions of fright or anxiety 
in some cases at the presence of a stranger or unaccustomed sur- 
roundings) that auditory sounds only reach a subconscious motor 
idea centre, and are thence immediately translated into speech. 
There is, in fact, a short-circuiting of the nerve current. This 
condition, as far as I am aware, does not occur in persons of 
normal mental development, although it is, of course, by no means 
uncommon for a person to speak who is totally unconscious of 
his surroundings. Many normal children, whilst busily engaged 
in some occupation, will repeat words which are pronounced near 
them, without seemingly understanding the words or being at all 
aware of the fact that they have copied them. It is presumably 
by a similar subconscious mechanism that echolalia occurs. 

It has already been mentioned that some aments have an 
extraordinary faculty for repeating sounds with extreme accu- 
racy. This ranges from the humming of a tune to the repetition 
of poetry or sentences in an entirely unknown tongue. The 
subject will be again alluded to under Idiots Savants, but it is 
worthy of passing mention in this place. 



CHAPTER VIII 

FEEBLE-MINDEDNESS IN CHILDREN 
(MENTALLY DEFECTIVE CHILDREN) 

The term feeble-mindedness is applied to the mildest of the three 
degrees of amentia. In the extent of their deficiency there is no 
difference between the feeble-minded child and adult ; but as the 
former are subject to the provisions of a special Act of Parlia- 
ment, which brings them within the jurisdiction of the education 
authority, it is necessary to consider them separately. In this 
chapter, therefore, we shall consider feeble-minded persons below 
the age of sixteen years, or, as they are designated in the Act, 
mentally defective children ; those over this age will be described 
as " feeble-minded adults " subsequently. 

After the passing of the Education Act of 1876, making attend- 
ance at public elementary or other schools compulsory, attention 
began to be directed to the educational needs of the mentally 
deficient. It became apparent that a group of children existed 
who were so far defective that they could not be satisfactorily 
taught in the ordinary public schools, but who were not suffi- 
ciently defective to be certified as imbeciles or idiots under the 
Idiots Act of 1886. Many particulars regarding this class were 
brought to light through the inquiries of medical men and 
scientific and philanthropic societies, amongst whom special men- 
tion must be made of Dr. Francis Warner, Dr. Fletcher Beach, Dr. 
Hack Tuke, and Dr. Shuttleworth ; the British Association, the 
British Medical Association, and the Charity Organization Society. 
The researches of Dr. Francis Warner in particular were of the 
most painstaking nature, and were based upon the examination 
of 100,000 school-children.* As a result of these inquiries, 

* See " Report on the Scientific Study of the Mental and Physical Con- 
ditions of Childhood," Parkes Museum, 1895 ; also " Report on the Feeble- 
Minded," etc., C.O.S., 1892. 

123 



i 24 Mental Deficiency 

a Departmental Committee of the Board of Education was 
appointed in 1896 to consider and report upon the question. 

This Committee pre ented its report in 1898.* It recognized 
that a number of children existed in public elementary schools 
who, in their mental capacity, were intermediate between the 
ordinary " dullards " and certifiable imbeciles, and it estimated 
the proportion of this class as approximately 1 per cent, of the 
elementary school population. Its inquiries showed that these 
children were incapable of receiving proper benefit from the 
ordinary instruction in these schools, but that they were capable 
of receiving considerable benefit from the individual attention 
and instruction given in special classes — that, in fact, under such 
conditions there was a fair prospect of many of them being 
enabled to take their place in the world. It considered that these 
defective children would suffer by association with imbeciles, 
and should not, therefore, be educated with them ; and it recom- 
mended that special classes and schools should be established 
to meet their requirements. This report led to the passing in 
the following year of the Defective and Epileptic Children 
(Education) Act. 

This Act (62 and 63 Vict., ch. 32, 1899) was the first legal 
recognition in this country of the mildest or feeble-minded grade 
of amentia. It defines the class as those children who, " not being 
imbecile, and not being merely dull and backward, are defective — 
that is to say, by reason of mental {or physical) defect are incapable 
of receiving proper benefit from the instruction in the ordinary 
public elementary schools, but are not incapable by reason of such 
defect of receiving benefit from instruction in such special classes 
and schools as are in this Act mentioned." 

This Act, therefore, clearly differentiates between the mildest 
degree of amentia and the more pronounced affection of imbecility, 
and although it does not apply the term " feeble-minded " to 
this class, the condition it defines is clearly identical with that 
to which this term has for long been specifically applied in this 
country. Mentally defective children are, in fact, the juvenile 
feeble-minded. The Act permits the local education authorities 
to establish special classes and schools for the mental defectives 

' * " Report of the Departmental Committee on Defective and Epileptic 
Children," 1898. 



Feeble-Mindedness in Children 125 

within their district, and where such are established attendance 
is compulsory up to the age of sixteen years, instead of fourteen, 
as in the ordinary schools. Unfortunately, owing to its permis- 
sive and not obligatory nature, the Act still remains a dead letter 
in many parts of the country ; but since it has been adopted by 
the whole of London, as well as by over twenty of the largest 
towns of England, the education of mentally defective children 
may now be said to have become an integral and important part 
of the educational system of the nation. 

The investigations instituted by the Royal Commission of 
1904 throw further light upon the number and condition of this 
class ; but, whilst agreeing in several respects with the conclu- 
sions previously arrived at, they differ on two important points. 

Firstly, as will be seen immediately, the 1 per. cent estimate is 
found to be somewhat too high ; secondly, a more extended 
experience of these children shows that the views which were 
formerly held as to the amount of amelioration under training, 
and their possibility of becoming self-supporting citizens, are too 
optimistic. 

Numerical Incidence. 

As the result of a careful analysis of the reports of the 
Royal Commission, I estimate that the mean average incidence of 
mentally defective children throughout England and Wales is 
073 per cent, of the children on the registers of public elementary 
schools. This number is somewhat lower than previous esti- 
mates, but as these inquiries, in addition to being more recent, 
were obtained under more favourable methods of examination, 
and also embrace a larger variety of districts, I am inclined to 
give preference to them. These figures, however, do not include 
defective children who, for various reasons, are not attending 
elementary schools, and if these be included the total number of 
mental defectives is raised to 0*83 per cent, of the school popula- 
tion. I calculate that in the whole of England and Wales the 
approximate total of these children is 50,665. 

But, as will be seen from the accompanying Table XIV., show- 
ing the percentages in the respective districts investigated, this is 
the mean average of two widely divergent extremes. In Durham, 
for instance, the percentage is only 0*24, whilst in Dublin it is 



126 



Mental Deficiency 



as high as 1-85, and it becomes necessary to consider the cause 
of these extreme variations. 

Much of the difference is clearly due to the fact that the 
incidence of mental abnormality in general (insanity and amentia) 
is not uniform throughout the country, but is subject to very 
considerable variations from causes which at present are not 
fully understood. This we shall not consider. But there are 
smaller variations which appear to be decidedly dependent upon 



TABLE XIV. 

Showing the Percentage of Mentally Defective Children to the 
Public Elementary School Population in Certain Districts 
investigated by the royal commission of 1904. 



Urban 



Industrial 



District. 
' Manchester 
Birmingham 
Hull . . 
Glasgow 
Dublin . . 
Belfast . . 

Stoke-on-Trent 

Durham 

Cork 



Mixed industrial / Nottinghamshire 
and agricultural \ Carmarthenshire 



Agricultural 



Somersetshire . 

Wiltshire 

Lincolnshire 

Carnarvonshire 

Galway 



Percentage. 

I*20 

1*03 

0-30 
074 
1 -8 5 
0-50 

o'59 
0-24 

o*35 

o-66 
076 

o-6i 
0-55 
0-96 
0-47 
i'33 



sociological and other influences, and since these relate, not to 
mental abnormality in general, but to the particular class with 
which we are now dealing, they must be referred to. 

Relative Incidence in Town and Country. — It has been 
shown that although amentia as a whole is more prevalent 
in rural, and insanity in urban, districts, and the number of 
idiots and imbeciles in the country far exceeds that in the 
towns, nevertheless the incidence of mentally defective children 
is decidedly greater in the towns than in the country. In 
view of the fact that these children differ only in degree, and 
not in kind, from the idiots and imbeciles, this is in itself singular ; 
but it becomes even more so when it is found that the feeble- 



Feeble-Mindedness in Children 127 

minded adult, who is simply the mentally defective child grown 
up, is not more prevalent in town than in country, but is actually 
less so. 

What, then, is the cause of this excess of mentally defective 
children in a town as compared with a country environment ? 

The answer which at once suggests itself is that the many 
adverse factors of the environment of our towns, the improper 
feeding, the faulty ventilation, the overcrowding, and, in fact, 
slum life generally, are responsible for the excess ; and since a 
history of morbid heredity is often very difficult to obtain in 
these cases, the (perhaps not unnatural) conclusion has followed 
that environment plays a very important part in the production 
of this mild degree of amentia. That feeble-mindedness may 
occasionally so result I do not deny, but I believe that the 
increased incidence of mental defectives in towns is to a great 
extent apparent only, and is due to the inclusion of a number 
of children who are not aments at all. 

In examining school-children in both town and country, I 
have often been struck by the fact that the ill-washed, ill-clad, 
and ill-fed — in short, the victims of faulty environment — were 
not as a rule the mental defectives. In fact, such children were 
often alert and quick-witted beyond the average, although 
probably by no means keen on book-learning. This fact led 
me somewhat to discount environment as being a frequent cause 
of amentia. Next, in examining certified mental defectives in 
special schools, I discovered a proportion of cases which I had 
no hesitation in saying were not aments at all, but merely suffer- 
ing from backwardness, and this caused me to make some 
inquiries as to the number of such children who recovered. 

Now, the essence of mental defect is that it is incurable, and 
by no "special" education, however elaborate, can a case of 
amentia be raised to the normal standard. Some defect must 
always remain, and upon this fact all authorities are agreed. 
When, therefore, it is found that a proportion of the urban 
defectives attending special schools are returned as cured to the 
ordinary schools, it is clear that an error of diagnosis has been 
made, and that they were not defectives. The proportion so 
returned varies very much in different towns, and in many the 
special classes have not been established sufficiently long to form 



128 Mental Deficiency 

a reliable test. The following is the percentage (of the admissions) 
of " mentally defective " children who have so far been returned 
cured to ordinary schools in some towns in which I made inquiries : 
Birkenhead, 6 per cent. ; Bradford, 15 per cent. ; Bristol, 3 per 
cent. ; Derby, 5 per cent. ; Leeds, 2 per cent. ; Leicester, 20 per 
cent. ; Liverpool, 4 per cent. ; London, 10 per cent. ; Nottingham, 
10 per cent. ; Plymouth, 8 per cent. ; Sheffield, 4 per cent. I 
think these figures show conclusively that a varying, and in 
some cases considerable, proportion of the town defectives are 
not aments at all. On this point I may quote the opinions of 
two physicians who have had large experience of these children. 
Dr. Evan Powell, of Nottingham, writes : " I agree with you 
that a large number of so-called defectives are in reality not so, 
but are merely suffering from temporary arrest." And Dr. Ralph 
Crowley, of Bradford, writes : " I have no hesitation in saying 
that, where many go back, the reason is to be found in the fact 
that the children in the first place belonged to the ' merely dull 
and backward group.' " 

I shall have occasion again to refer to these cases of delayed 
development, which simulate mental defect, in speaking of 
diagnosis ; but I have thought it well to allude to them here for 
the reason that the neglect to distinguish them may cause 
totally erroneous views as to the increased prevalence of mental 
deficiency in towns, as well as of its cause and its possibility of 
cure. It seems to me probable that the real incidence of defect in 
town is not much, if any, greater than in country districts. 

With regard to the social status of these children there is 
little to be said. The labouring classes have no monopoly of 
morbid heredity, and, although I am unable to give any actual 
figures, my general impression is that mental defect is just as 
prevalent amongst the upper as the lower classes of this country. 

With regard to sex, there is a considerable preponderance of 
males, the relative proportion of boys to girls being practically as 
three to two. 

Description. 

Mentally defective or feeble-minded children differ greatly in 
the degree of their deficiency. The lower members of the class 
closely approximate to, and cannot be distinctly separated from, 



Plate III. 
MENTALLY DEFECTIVE SCHOOL-CHILDREN. 





Fig. ii. 



Fig. 12. 





Fig. 13. 



Fig. 14. 





Feeble- Mindedness in Children 129 

the imbeciles. The higher members, on the other hand, are 
but little removed from the merely dull and backward of the 
normal population. It is therefore clear that no general descrip- 
tion can be given which would be applicable to every mentally 
defective child ; but the following are the chief characteristics 
of the class. Illustrations of the milder degrees are shown in 
Plate III. 

Physical Condition. — A small proportion of children suffering 
from mental defect would pass muster as normal if their diag- 
nosis rested upon inspection only ; but such cases are exceptional, 
and the majority present unmistakable anomalies of bodily 
structure or function, as well as of mental development. 

Anatomical anomalies, or so-called stigmata of degeneracy, 
are usually neither so plentiful nor pronounced in the feeble- 
minded child as in the imbecile or idiot ; nevertheless Dr. Lapage, 
as a result of his examination of 200 children, found such to 
occur in no less than 90-5 per cent, of the total number examined. 
The defects were usually in combination, and in 2373 per cent, 
were triple. In my experience the cranium is the most common 
site of defects, and I believe it to be abnormal either in shape or 
size, asymmetrical, bossed, or ridged, in fully half of these 
children. When the child first comes to school, and between 
the ages of seven and ten or twelve years, the maximum circum- 
ference is usually about half an inch less than that of a normal 
child of corresponding age and sex ; but this discrepancy becomes 
mere and more marked, and by the fourteenth or sixteenth year 
the difference may be as much as an inch, or even more. Next 
in frequency to the cranium, anomalies of the palate are found ; 
whilst malformations of the external ear and of the eye and its 
appendages occur a little less often. 

Inquiries will nearly always show that in these children 
dentition, standing, walking, and speaking have been abnor- 
mally delayed. It may be four, five, or even six years before the 
child says a word. This retardation continues with advance 
in years, so that at every period of its school-life the mentally 
defective child compares unfavourably in its bodily growth and 
acquirements with the one of normal intellect. Moreover, the 
bodily functions are often imperfectly performed : the circula- 
tion is feeble, so that chilblains and sores are frequent in cold 

9 



i jo Mental Deficiency 

weather; assimilation is defective, consequently the child 
remains thin and ill-nourished ; the vitality generally is dimin- 
ished and catarrhs and ill-health are exceedingly common. It 
was ascertained by Dr. Ashby that the children in special schools 
at Manchester averaged 2 to 4 inches less in height and 3 to 
12 pounds less in weight than the normal. To some extent 
this may be due to the nature of the environment in these cases. 
As already stated, the home conditions of the feeble-minded are 
often very faulty, and I have usually found that the defectives 
in the country are sturdier and of better physique than are those 
in the towns ; but this is not the full explanation, for the same 
applies to normal children, and, whatever their situation, mentally 
defective children compare unfavourably with their mentally 
sound fellows. 

Abnormalities of Nerve Action are very frequent. In some 
children there is a general diminution of activity, and such are 
heavy stolid, tardy in response, and laboured in all their move- 
ments. In others the reverse is the case, and all movement is 
in excess. Such children cannot sit or stand still ; they are 
distracted from their task by every little thing around them, 
and they are often full of " tricks " and " habits." Co-ordination 
of movement is slowly and laboriously acquired. The making 
of pothooks and hangers presents difficulties unknown to the 
ordinary child, and paper-folding, card pricking, and the simple 
kindergarten occupations are in the first instance performed 
with a laborious clumsiness. Many of the milder defectives, as 
a result of special training, do learn to use their hands extremely 
well but even these rarely acquire the degree of dexterity 
attainable by an ordinary child who has been similarly trained. 
In some instances speech is accompanied by "spreading 
action, as seen in corrugation of the forehead, grinning, and at 
times twitching of the whole body. 

The net result of these anomalies of nerve action is a pecu- 
liarity of balance and movement and of physiognomical expres- 
sion which is exceedingly characteristic of the class, and which 
frequently enables the expert to detect mental deficiency at a 
glance The expression varies from a look of heavy, immobile 
stupidity and vacuity, which is chiefly seen in those lacking in 
action to a general restlessness and inattention to the subject 



Feeble-Mindedness in Children i 3 1 

in hand, often accompanied by spasmodic twitches, tricks, and 
habits, which is characteristic of those in whom action is excessive- 

Speech, as well as being late in making its appearance, is 
defective in fully one-third of these children. It is very rarely 
lacking entirely, although the speech of some children, before 
training, is so imperfect as to be quite unintelligible to a stranger. 
The chief defects consist of a thickness and indistinctness of 
utterance, an imperfect articulation of consonants, and (rarely) 
stammering and stuttering. The former of these conditions is 
partly attributable to abnormal configuration of the palate, lips, 
jaws, or pharynx, and partly to a general brain inertia and 
inability or unwillingness to make the effort necessary for distinct 
enunciation. The consonantal defects are due to similar causes 
plus a want of co-ordination. It may be remarked that in- 
ability to pronounce, not one in particular, but many consonants 
is very commonly indicative of mental deficiency. 

Mental Condition. — Sensation. — In a small proportion of 
these children sensation is imperfect by reason of disease or 
anomalies of the peripheral or central organs ; but on the whole 
serious sensory defects are not a prominent feature of the feeble- 
minded degree of amentia. Defects of hearing (which are 
generally due to disease of the middle ear) are present in about 
8 per cent., and defects of vision in about 15 per cent., of cases. 
Colour-blindness, although in many cases seemingly present, is 
not in reality any more common than in ordinary children. 

But there is a great difference in the educability of the percep- 
tive faculties of feeble-minded children. The ordinary healthy 
child possesses an initiative and enterprise which brings him 
into daily contact with sights, sounds, and impressions of every 
description. His faculties of attention and curiosity cause him 
to observe, smell, and handle everything he meets, and in conse- 
quence the range and delicacy of his sensorium soon becomes 
very considerable. The feeble-minded child is defective in many 
of these qualities ; consequently the development of his sen- 
sorium has to be aided and encouraged by special means, and 
until this has been done his power of sensory discrimination is 
decidedly inferior to that of the normal child of similar age. I 
have frequently observed that, upon their admission to a special 
school, the sensory capacity of defective children is compara- 

9—2 



132 Mental Deficiency 

tively obtuse, and that they have little ability to discriminate 
between sensory impressions of the same order, but of slightly 
differing intensity. Under suitable training much of this is 
remedied, and the sensory functions of many of the milder types 
who have been thus trained does not seem to be much inferior 
to the normal. But the lower types are lacking in this power 
to develop, and in them the most persistent special training 
fails to bring the sensorium up to the normal level. In this 
latter class the organic sensations of pain, cold, hunger, and 
discomfort are also somewhat obtuse, but these do not appear 
to be so much affected as do the special senses. 

Attention. — In the lethargic, inert type of feeble-mindedness 
there is a defect of spontaneous attention ; but this is never so 
marked in this degree as in the more serious grades of amentia. 
The general stir and excitement aroused by a visitor is much 
more pronounced in the special school than in the imbecile 
ward. On the other hand, active or voluntary attention is 
commonly in defect, both with regard to its intensity and its 
duration. The most trifling thing serves to distract these 
children from their occupation, so that even where the attention 
is readily gained, it is with difficulty held. Many of them become 
capable of pursuing a congenial task with a certain amount of 
patience, but the majority have neither power of concentration 
nor will sufficient to be capable of sustained mental effort 
against inclination or interposed obstacles. They must go with, 
for they cannot fight against, the stream ; and this lack of will- 
power and driving force is one of the most distinguishing charac- 
teristics of aments at all ages. 

School-teachers often complain of the lack of memory of these 
children, and if this faculty is to be judged by their inability 
to remember items of scholastic knowledge, there would certainly 
appear to be a decided deficiency. Some of them have very great 
difficulty in connecting a word with a thing, or in recognizing a 
printed character or numeral as the symbol of a concrete object 
or number of objects. It is the same with colours : many can 
match colours perfectly well, thus proving that their colour- 
sense is not defective, and yet they may constantly confuse the 
names of colours. It is probably this which has given rise to 
the impression that colour-blindness is common amongst them. 



Feeble-Mindedness in Children 133 

It is not to be expected that such a child would remember 
historical or geographical data, but the defect seems to be rather 
one of association and comprehension of the abstract than of 
memory proper. In the tenacity of their memory for things 
which are really understood, I have been unable to satisfy 
myself that feeble-minded are at all inferior to normal children, 
and many of them retain items of knowledge which have been 
demonstrated by concrete examples, as in object-lessons, remark- 
ably well. 

As a class, mentally defective children are imitators rather 
than originators. They may faithfully reproduce, but they 
rarely create, and their faculty for evolving new ideas — imagina- 
tion — is decidedly lacking. But some of them evince consider- 
able cunning in the commission of misdeeds, as well as no little 
ingenuity in the invention of lies to escape the consequences ; 
and in many there is abundant evidence of the existence of the 
day-dreams and flights of fancy which figure so largely in the 
mental life of the normal child. I have often seen them look 
forward with delight to the approaching Christmas-tree, and 
several of my little patients have taken me into their confidence 
in recounting their ambition to be a judge, a soldier, sailor, 
policeman, or engine-driver. Nevertheless, the fact remains 
that in constructive imagination and inventiveness there is 
usually a considerable defect. 

Control is very feebly developed in these children, and action 
is always along the line of least resistance. Volition is by no 
means absent, but their behaviour is more often the result of 
sudden desires and impulses than of deliberate purpose. They 
are capable of such simple feelings as pleasure, pain, fear, 
astonishment, anger, surprise, and the like ; but their emotions, 
like their sensations, are usually weak and evanescent. They 
are rarely stirred by hate, indignation, anguish, awe, or a con- 
sciousness of the sublime. They are readily amused by any- 
thing ridiculous and touched by anything pathetic ; but they 
have little real sense of humour. 

All of them are lacking in the logical, and most of them in the 
esthetic, sense. In a small proportion there is, in addition, a 
marked deficiency or perversion of the moral sense, and such 
will lie, pilfer, and generally misconduct themselves, without the 



134 Mental Deficiency 

slightest compunction. Some of this type are exceedingly 
cunning, and a few are guilty of acts of marked cruelty to other 
children or to dumb animals. They will also make utterly un- 
founded accusations with a considerable amount of detail and 
appearance of truth. On the other hand, there are many who 
are contented, obedient, well-behaved, and affectionate, and 
they may even possess a tolerable conception of their moral and 
religious obligations. Some are capable of understanding and 
being influenced by simple theological doctrines, but on the 
whole the religious sentiment in these children is of a decidedly 
poor order. 

Scholastic Acquirements. 

All these children are greatly improved by suitable training, 
but their developmental capacity and response to education 
vary enormously. On this account it is convenient to divide 
them into three grades. 

The first grade is composed of children who make tolerabl e 
progress in elementary school knowledge. They are capable of 
writing a simple letter, they can read children's books, and they 
can perform simple arithmetical exercises mentally, as well as 
the first four rules on paper. They have a knowledge of money 
values, and they can be trusted with simple commissions. Their 
handiwork is often extremely good, and they do little drawings, 
brush-work, cutting-out, basket and wicker work, rug-making, 
and the like, with a dexterity which is often surprising. They 
have some common sense, but they lack resource and judgment, 
and often initiative. 

The second grade fall considerably behind the former in 
purely scholastic attainments, and also, although not to the 
same extent, in handicraft. They are rarely capable of mental, 
and seldom of paper, arithmetic, and their reading and writing 
ability extends no further than simple words of one syllable. 
Some are even unable to do this. 

They can perform the same kind of manual work, but the 
result is not nearly so good, and they require more constant 
stimulation as well as much closer supervision. They have 
decidedly less general intelligence. 

The third grade form a connecting link with the imbeciles, 



Feeble-Mindedness in Children 135 

from whom, indeed, they are but little removed. The improve- 
ment effected by the special school is limited to the develop- 
ment of some capacity for manual work under supervision, and 
to the formation of habits of obedience, tidiness, and regularity. 
Their scholastic acquirements are practically nil. 

As a concrete example of the difference between mentally 
defective and normal school-children, I may give the following 
brief account of the pupils attending a typical " special " school 
under the London County Council. 

This school* contains over sixty defective boys and girls, who 
are divided into three separate classes, each under a mistress. 
In the lowest class the average age of the children is from eight 
to nine years, the youngest being seven and the oldest about 
twelve years. In age, therefore, they correspond approximately 
to normal Standard II., in which the school-work consists of — 
Reading equivalent to iEsop's "Fables." Writing: transcrip- 
tion and dictation equal to the same. Arithmetic : tables up to 
12 x 12 ; pence table ; compound addition, subtraction, multi- 
plication, and division ; four simple rules and problems intro- 
ducing two or more rules at one time. Drawing : simple free- 
hand ; use of ruler and set -square. Geography. History. Object- 
lessons in animal and vegetable life and simple science. 

The work actually done by the defective children in this class 
consists of recognition of letters of the alphabet and reading 
words of three or four letters ; transcription of the same from 
a blackboard copy ; recognition of simple numerals, and writing 
the same from dictation ; simple addition up to ten and simple 
subtraction of single figures. None are capable of writing from 
dictation, and all sums are done in the concrete by means of 
beads or tablets. In addition, the children are taught the use 
of the ruler ; they learn simple paper folding and cutting, 
brush-work, and rough clay modelling. They also engage in 
musical drill and games. 

The average defective child takes two years before he or 
she becomes proficient enough to be passed out of this class. 
Some never do attain to this proficiency, although they may be 
moved up on account of their size. A few are sufficiently 

* Goodrich Road Special School, East Dulwich, S.E.. in the charge of 
Miss N. Mumbrav. 



136 Mental Deficiency 

advanced to be transferred after six months, but I am of opinion 
that the majority of these are not really defective, but merely 
dull and backward. 

In the middle class the average age is from ten to eleven, 
the youngest being eight and the oldest sixteen years. It thus 
corresponds to normal Standard IV., in which the work consists 
of — Reading from Geographical, Historical, and Literary Readers. 
Writing, the same, with short essays and letter-writing. 
Arithmetic : simple exercises in money, time, weights and 
measures ; simple vulgar and decimal fractions. Geography, 
History, Grammar, Object-lessons, and Drawing, all more ad- 
vanced. 

The work actually done in this class is reading simple words 
of one and two syllables from Infant Reader I. ; transcription 
and dictation in simple words of one and two syllables ; addition, 
in the abstract, of simple numbers up to 100 ; subtraction of 
tens and units ; simple multiplication and, rarely, simple division 
by one figure. The occupations consist of rather more advanced 
brush-work, paper-folding and threading, cutting paper in the 
form of leaves for flower-making, and clay-modelling. The 
average time spent in this class is about two years. 

In the highest class the average age is twelve years, the 
youngest being ten and the oldest nearly sixteen. One-fourth 
of the pupils are over thirteen. They thus correspond in age 
with Standards VI. and VII., in which the school-work consists 
of — Reading from more advanced Literary, Geographical, and 
Historical Readers. Writing, the same, with short original essays 
on geographical and historical topics. Arithmetic : simple and 
compound practice ; problems in greatest common measure and 
least common multiple ; the first four rules in vulgar and decimal 
fractions. Grammar, with analysis and parsing. More advanced 
History and Geography. Geometry and Model-drawing. Elemen- 
tary lessons in Physics and Chemistry. 

The work done by this class consists of reading and writing 
equivalent to normal Standard II. ; compound addition and 
subtraction up to 1,000, and simple multiplication and division. 
Excluding a few children — who, in my opinion, are not really 
defective — it may be said that the scholastic acquirements of 
none of these children come up to normal Standard II. In 



Feeble-Mindedness in Children i 37 

occupations and manual work they are decidedly better, and a 
considerable proportion of the children in this class can cut out 
and make simple artificial flowers, knit rugs and weave baskets, 
with a really very creditable amount of dexterity, which re- 
dounds in no slight measure to the patient, persevering, and 
systematic care of their teacher. 

With the object of testing their capacity for attention, memory, 
and general comprehension, Miss Mumbray was good enough to 
place for me a collection of twelve small articles, such as a 
pencil, tape, bottle, scissors, etc., on a board, and let the children 
look at them for two minutes. The board was then removed, 
and the children given ten minutes in which to write down, 
either in words or graphically, the things they had seen. Out 
of eighteen competitors, all but one found it easier to draw than 
to write the names of the objects ; five children remembered the 
whole twelve articles, four remembered eleven, four ten, one 
nine, one eight, two seven, and one only five. In the majority 
of the children the drawings were sufficiently good to enable 
me to readily recognize the several objects for which they were 
intended, whilst some were really excellent. 

Such are the chief abilities and disabilities of mentally defective 
children. They differ, however, not only in the degree of their 
deficiency, but also in their temperament, disposition, and general 
behaviour. In fact, they possess individuality just as do normal 
children, although this is not, as a rule, a pronounced and domi- 
nating feature until after puberty. Moreover, there are certain 
readily recognizable clinical types of these children, just as there 
are of aments in general, whilst superadded complications are not 
uncommon. The great majority suffer from primary amentia, 
and although most of these are of the simple variety, between 
5 and 10 per cent, are microcephalics, about 2 or 3 per cent, 
macrocephalics, and about the same number are of the Mon- 
golian variety. In probably about 10 to 15 per cent, of these 
children the amentia is of the secondary form, most of them 
being of the vascular or post-febrile varieties. In a small propor- 
tion of these some degree of paresis or paralysis is present, although 
this is neither so prevalent nor so severe as in the imbeciles 
and idiots. Another small proportion are cretins, and in a still 
smaller number there is evidence of syphilis. Indications of 



138 Mental Deficiency 

rickets are not uncommon, whilst in about 10 per cent, of cases 
the feeble-mindedness is accompanied by epilepsy. 

But whatever the particular features may be, there is one 
quality which characterizes all the varieties and grades of these 
children, and that is their inability to swim against the stream, 
or even to keep their heads above water, without the assistance 
of some kindly hand. Whilst the ordinary child of fourteen or 
sixteen years has not only a considerable knowledge of common 
things and events, but has in addition acquired notions of 
qualities and conceptions of the abstract ; whilst he has developed 
the faculty of comparing, relating and judging between these 
conceptions, and of tracing a connexion between cause and 
effect ; whilst his mind now enables him to take an intelligent 
interest in his daily work, and allows him to shape plans for his 
future ; whilst, in short, he has learned to put away childish 
things and has become capable of standing alone — the mentally 
defective one of similar age is still happy with his toys, and his 
whole behaviour and conversation still indicate the infantile 
and imperfect character of his mind. Bodily and mentally he 
is always in arrears, and with each advancing year his intellect is 
left farther and farther behind that of his more fortunate fellow. 
His special training has done much for him, in so far as it has 
inculcated habits of regularity and conformity to the will of 
others ; further, and more important, because it has converted 
him from a useless, and often dangerous, member of society into 
one capable of some amount of useful work. But this latter can 
only be accomplished under supervision, and the future of the 
feeble-minded child, as he passes out of the door of the school 
for the last time into the great world beyond, will entirely depend 
upon how thorough and careful this supervision is. 



Diagnosis. 

Owing to the Defective Children (Education Act) of 1899, the 
diagnosis of this condition has become a matter of considerable 
importance, and merits our special attention. It may be 
remarked that parents sometimes resent a diagnosis of mental 
defect, and the examiner may be called upon to convince a 
magistrate of its accuracy, in order to enforce attendance at a 



Feeble-Mindedness in Children 139 

special school. The points to be considered are : (1) The family 
history ; (2) the personal history ; and (3) the present state of 
the child. All these are of importance. 

With regard to the family history, we have seen that morbid 
heredity occurs in a very large proportion of cases ; consequently 
its presence or absence in any given child is an indication of 
value. In secondary amentia, however, it is absent ; and even 
where existing in primary cases, it must be remembered that 
its ascertainment may be a matter of very great difficulty. In 
a large number of these children it is impossible to elicit more 
than the most fragmentary family history. 

In investigating the personal history, inquiry must first be 
made as to whether the child's mental condition is of recent or 
long standing. In most cases of real amentia of the primary 
form, it will be found that some dullness or peculiarity has been 
noticed from infancy, and that there has been a general retarda- 
tion of physiological development (see table of normal develop- 
mental data, p. 364). Thus, the child has usually been back- 
ward in cutting his teeth, in sitting up, in attempting to stand, 
to walk, and to talk. Delay in any one of these particulars is 
of little importance, for the range of normal variation is very 
considerable ; but delay in several particulars, provided there is 
an absence of bodily disease, such as rickets, etc., must be re- 
garded as very suspicious, particularly if accompanied by a neuro- 
pathic family history. Exceptions to this occur in cases of 
delayed primary or developmental amentia, in which, although 
morbid heredity may be present, the bodily and mental condition 
of the child are often normal prior to the advent of some infan- 
tile illness or other determining factor. 

Most cases of secondary amentia are the result of epilepsy, or of 
some serious toxic or vascular lesion of the brain, of which there 
will usually be a clear history. Prior to this the child's condition 
has been normal. 

Lastly, the child himself must be carefully examined. In 
doing this it is necessary to remember that many children, 
whether defective or sound, are nervous and ill-at-ease under 
examination, and I think that a large number of mistakes in 
diagnosis arise from the inspector's failure to gain the child's 
confidence. This should be the first concern, and the whole 



140 Mental Deficiency 

examination must be quiet and deliberate, but kindly and free 
from the slightest appearance of harshness. The child must, 
of course, be compared with his compeers in age and social 
position. 

The first point to be attended to is the physical condition, 
paying particular attention to the presence or otherwise of 
illness or disease, anatomical and physiological anomalies or 
stigmata of degeneracy, and abnormal nerve signs. The state 
of nutrition and the general physiognomy must also be carefully 
considered. By this examination indications of great value will 
be forthcoming. 

Finally, an examination must be made of the child's mental 
condition. This is done by conversation, careful consideration 
of his manner, behaviour, general conduct, and scholastic and 
manual ability. It is impossible to lay down any precise rules, 
and skill in diagnosis can only be gained by a constant association 
with the class and familiarity with their characteristics as described 
in the preceding pages. There is no single psychological test ; but, 
as we have seen, the chief mental peculiarities of these children 
consist in a lessened range and acuteness of perception, defect 
of voluntary attention, crudity and childishness of ideas, feeble 
reasoning power and will, and, above all, deficient " common 
sense." In their general mental development and capacity, 
especially in their scholastic attainments, these children are 
markedly behind normal ones of similar age ; although, as will 
presently be seen, inability to progress in school is by no means 
diagnostic of mental deficiency. 

Dr. Warner says : " The trained observer can read off the 
physiognomy of the individual features and their parts, the 
facial condition and eye movements, the balance of the head 
and body, etc., as quickly as a printed line." To this I would add 
that the expert who has meanwhile been chatting with the child, 
by the time he has proceeded thus far, will also have arrived at 
a tolerably accurate estimate of the degree of mental capacity. 
A few simple tests as to the condition of the special senses, the 
extent of memory, the power of reasoning, and the scholastic 
and manual attainments, supplemented by particulars from the 
teacher or parent as to the child's habits and special propensities, 
will usually provide him with all the data necessary for diagnosis. 



Feeble-Mindedness in Children 141 

The Act of 1899 requires the mentally defective child to be 
differentiated from the " merely dull and backward " and the 
imbecile. It may therefore be useful to refer to the chief features 
of these, as well as some other not uncommon conditions of 
childhood, which may more or less closely simulate mental 
defect. 

Dull and Backward Children. — The " dull and backward " 
children are the least intellectually gifted members of the normal 
population. They are a numerous group, but their proportion 
varies considerably in different localities. In some parts of 
Somersetshire I found them to the extent of 5 per cent., in 
others from 15 to 20 per cent., of the school population. On the 
whole, I think they are commoner in country than in urban 
districts. These children fall into two classes, according to 
whether the backwardness is confined to an inability to acquire 
school learning only, or affects the whole mental faculties. The 
former class are, as a rule, readily distinguished ; but in the 
latter diagnosis may be a matter of much difficulty. 

As an example of the dullards or dunces, I may mention the 
case of two brothers, aged ten and twelve respectively, who, 
during my examination of a large country school, were produced 
by their teacher as being very bad cases of defect. They were 
both in Standard II., and my examination showed that they 
were certainly unequal to the work. But I soon found that they 
had a very good knowledge of many details of country and 
farm life — of the cows, the corn, and the bird-nesting, and that 
they were by no means backward in the playground. In fact, I 
had little difficulty in demonstrating to the teacher that, although 
these boys could hardly do the simplest sum, and could only 
read and write words of one syllable, yet they had plenty of 
common sense, and were by no means mentally deficient. I 
have frequently found this failing to run in families, and in a 
conversation on this subject with an intelligent old dominie of 
a country school, I was shown an excellent example in three 
members of one family who were present in school at that time, 
and who were such hopeless dunces that their attendance seemed 
a complete waste of time. My informant told me that the 
father of these children, and his brothers and sisters, had all 
been through his hands in their turn, and they were just the 



142 Mental Deficiency 



same ; but although the father could only just manage to scrawl 
his name, and could not read the newspaper, he nevertheless 
worked a small farm with complete success. Children of this 
kind occur in the towns also, and although they cannot or will 
not (I think it is a little of both) make any headway with their 
lessons, they are as sharp as needles on the playground and in 
the streets. 

It is possible that some observers would consider this condition 
to be one of mild, but none the less real, mental defect. I do 
not think, however, that they should be so classed. Their family 
history is generally good ; they are sturdy, well grown, free from 
stigmata of degeneracy, and fully up to the average in every 
faculty except ability to acquire book-learning. It seems to me 
that they are perfectly normal, and not diseased specimens of 
mankind, and that their condition is simply one of a somewhat 
tardy evolution of certain faculties, the result of the manner of 
life of generations of. ancestors. However this may be, I am 
sure that inability to progress at school is not necessarily indica- 
tive of mental defect, and this fact the medical examiner must 
keep in mind, and not be led into a too hasty diagnosis from the 
school report only. 

But in a certain number of children the backwardness is not 
confined to school-work ; it is general. These children are not 
only dunces at learning, but they are dull at games and in out- 
door and home life ; in fact, their whole demeanour and behaviour 
are characterized by a more or less dull stolidity. Here, again. I 
do not think the condition is necessarily one of mental defect ; 
it is physiological, and not pathological, although undoubtedly 
it is the normal in its lowest mental form. It is these 
cases which cause no little perplexity to the medical examiner, 
and an accurate diagnosis will need all his skill and experience. 
Perhaps the following points will help : The family history is 
decidedly useful, because if morbid heredity is at all pronounced 
it is highly probable that the case is one of real defect. I do not 
think that information as to the previous personal history is of 
much value, for most of these generally dull and backward children 
resemble the real defectives in having been in arrears all along. 
A careful examination of the child is of the greatest importance. 
In a considerable number of defectives there are stigmata of 



Feeble-Mindedness in Children 143 

degeneracy and abnormal nerve signs ; these are usually wanting 
in the cases we are now considering. Further, the dull and 
backward are usually well developed and of good nutrition — often, 
indeed, fat and robust ; whilst the feeble-minded are usually of 
defective stature, thin, and ill-nourished. Finally, and most 
important, the child must be carefully questioned in such a way 
as to reveal his general knowledge of common objects and his 
probable course of action under everyday circumstances. By 
this means his general mental capacity will be gauged, and the 
examiner will be able to form an opinion as to whether he has 
sufficient wit to take care of himself. If, in spite of his mental 
dullness, he seems intelligent enough to follow an occupation, and 
to look after his interests with ordinary prudence, then he is not 
defective. The subject of moral defect will be considered in a 
separate chapter. 

Children of Delayed Mental Development. — We now come to a 
group of children of a totally different kind, the retardation of 
mental development being only temporary. This condition, 
unlike the preceding, is much commoner in our large towns than 
in the country, and it often simulates real amentia so closely 
that for a time a diagnosis may be impossible. 

It has already been stated that certain factors of the environ- 
ment may possibly, but very occasionally, produce mental 
defect. More commonly, however, the insufficient and improper 
feeding, the absence of fresh air or warmth, and the general neg- 
lect which unfortunately attaches to the early life of many of the 
children in our densely populated industrial centres, produce a 
retardation of mental growth which is not permanent, and is not 
therefore amentia. In real amentia there is either an actual and 
permanent arrest or an incapacity for perfect development, owing 
to a blight of the seed. In these cases it is the soil which is 
unsatisfactory, and the condition may not inaptly be compared 
to the late opening of the flower-buds in consequence of chill 
winds and absent sun. It is what may be described as a late 
Spring, and the characteristic of these cases is that under more 
congenial surroundings the brain rapidly recovers, and the child 
soon regains the normal standard. It may be several years before 
this change takes place, and it often does so with surprising" 
suddenness ; so that the child who has hitherto been dull, vacant, 



144 Mental Deficiency 

and apparently suffering from undoubted mental deficiency, 
astonishes everybody by suddenly waking up. 

I have already referred to these cases, and have shown that 
they form a variable, but often considerable, proportion of the 
pupils of " special " schools. There is, of course, no objection 
to their admission to these schools — in fact, the individual atten- 
tion and special training thereby afforded are the very best things 
for them. It is, however, extremely desirable that the condition 
should not be confounded with real defect, as this leads to 
entirely fallacious ideas as to the prevalence, causation, and 
curability of amentia. It must be admitted that the diagnosis 
is often extremely difficult, and may be impossible until the 
touchstone — special training — has been applied. I think, how- 
ever, that if the examination reveals an entire absence of morbid 
inheritance, if there are no stigmata of degeneracy nor signs of 
irregular nerve action, and if the state of nutrition is poor and the 
environment is known to be bad, that then there are grounds for 
suspecting that the case is one, not of arrested, but of retarded, 
development, and the diagnosis must be provisional accordingly. 

Dullness due to Disease. — Children suffering from defects of 
vision, hearing, speech, or from serious constitutional disease, 
often appear to be dull and stupid, and might possibly be thought 
to be mentally defective. I do not think that the physician 
would be very likely to fall into this error, but it is necessary 
to bear the fact in mind, as such a mistake is often made by 
school-teachers. I have had boys and girls produced as cases 
of serious defect who merely wanted the attention of the oculist 
or nose and throat specialist, and I have examined a child 
returned as defective who was mentally sound, but suffering from 
severe pulmonary tuberculosis. Ordinary care should suffice to 
prevent these mistakes, although the presence of illness or disease 
does not, of course, negative mental defect. 

Another condition, more often seen in the consulting-room 
than the school, which may give rise to a suspicion of amentia 
is that of nervous exhaustion. The child is dull, listless, and 
inattentive. He cannot be got to answer questions, and if given 
a simple sum he does it wrong. His co-ordination is imperfect, 
his memory is faulty, there is often tremor, his head may be small 
and asymmetrical, and his lower eyelids are baggy and relaxed. 



Feeble-Mindedness in Children 145 

The history will generally show that the mental hebetude is of 
recent origin, and that previously the child has been of ordinary, 
sometimes unusual brightness ; but as against this the inquirer 
may elicit a neuropathic family history. The condition here is 
probably one of neurasthenia in a child with but a small reserve of 
nerve force. It is often accompanied by severe headache, and is 
usually the result of overpressure. These children form the class 
from which a considerable proportion of the insane population is 
drawn, and although most cases recover under suitable treatment, 
the dullness of mind occasionally persists until the child becomes 
a complete mental wreck. In older children this state may owe 
its origin to masturbation. 

Epilepsy. — It is necessary to remember that, although the 
mentally defective child may be subject to fits, epilepsy may 
give rise to a transitory mental dullness which is not amentia. 
In most of these cases there will be a history of fits, but they may 
be nocturnal only, and unknown to the parents. The physician 
will then have to be guided by the loss of memory and alternating 
brightness and stupidity, which have little in common with the 
fixed mental state of the real defective. In many of these cases, 
however, amentia, and subsequent dementia, may be induced. 

Insanity might possibly be confused with mental defect, but 
the relative rarity of this condition, and the usually evident fact 
that the child is suffering from a disorder, and not an arrest of 
mind, ought to prevent such a mistake. 

Imbecility. — Having ascertained that the mental condition of 
the child under examination is not due to disease or ill-health, 
is not merely dullness and backwardness, but is really one of 
deficiency, the physician who is examining for the purpose of 
certification to a special school will be required to exclude im- 
becility. In pronounced cases of this latter there will be no 
difficulty, but in the milder degrees a differential diagnosis will 
be far from easy. The following points may be found of assist- 
ance : 

As a rule, the mentally defective school child knows the names 
of common objects, and can give some account of their use, whilst 
the imbecile of corresponding age is generally lacking in this 
knowledge. Neither child may know his letters, but the mentally 
defective will usually recognize and name various articles shown 

10 



146 Mental Deficiency 

to him in pictures. Speech is often a valuable indication, although 
it is to be remembered that many merely feeble-minded children 
speak exceedingly badly. It is rather the matter than the 
manner of speech which must be attended to, as showing the 
degree of general intelligence. Some imbeciles will repeat ques- 
tions ; others obviously fail to understand what is said to them ; 
others ramble on in an utterly nonsensical manner, and are quite 
incapable of carrying on the simplest conversation. The inability 
to execute some simple command or the manner of doing so often 
affords most useful information. Above all, however, the im- 
becile is markedly deficient in common sense. He can rarely be 
depended upon to perform any simple errand or task unless 
watched the whole time, and he often will sit outside in the rain 
and get wet through without making the slightest effort to 
shelter. 

If there should be any doubt in the examiner's mind, then I 
think it is kinder to give the child the benefit of it. It may seem 
a small matter, but it is to be remembered that for children of 
the working classes, who cannot afford to pay considerable fees, 
the only alternative to the special school is often the workhouse 
or county asylum. Excellent special idiot asylums exist, it is 
true, but in the absence of means admission into these is often a 
tedious process. I should certainly hesitate to commit a possibly 
improvable case to an institution which does not profess to have 
training facilities, until he had been tried, and found wanting, in 
a special school. 



CHAPTER IX 

FEEBLE-MINDEDNESS IN ADULTS 

Definition. — The term feeble-minded person is applied to an 
individual suffering from the mildest degree of amentia, who is 
over the age of sixteen years, those under this age being known 
as " mentally defective children." 

The feeble-minded person is denned as " one who is capable of 
earning a living under favourable circumstances, but is incapable, 
from mental defect existing from birth or from an early age, (a) of 
competing on equal terms with his normal fellows, or (b) of manag- 
ing himself and his affairs with ordinary prudence." 

Number. — The inquiries of the Royal Commission show that 
about 40 per cent, of all aments in this country are feeble-minded 
persons, and I calculate that in England and Wales on January 1, 
1906, their approximate total was 54,114. This number is rather 
less than half the total insane on the same date, and corresponds 
to 1 -57 feeble-minded persons in every 1,000 population. But the 
incidence is not uniform throughout the country ; it varies 
directly with the prevalence of mental abnormality in general 
(which is subject to a very considerable range of variation) ; it 
also differs according to the environment. The prevalence in 
the respective areas investigated has been shown in Tables I. and 
IV., pp. 6 and 10, from which it is seen that the feeble-minded 
adult, both absolutely and relatively, tends to be commoner in 
agricultural than in urban districts. 

The cause of this is not at first sight clear, for these persons are 
but grown-up defective children, and this latter class is apparently 
much more numerous in the towns than in the country. As I 
have shown, however, there is good reason for thinking that a 
large proportion of the so-called mentally defective children of 

147 10—2 



148 Mental Deficiency 

our towns are not defective at all, but simply suffering from 
delayed development ; so that the real incidence of mentally 
defective children is probably not appreciably greater in urban 
than in rural areas. In addition, the increased competition of 
town life is decidedly unfavourable to the feeble-minded adult, 
and there is evidence to show that as a consequence a certain 
number of those born in towns are gradually squeezed out into 
the country. 

Sex. — On the whole, males and females occur to about an 
equal extent, and the investigations of the Royal Commission 
show that, of a total of 4,291 feeble-minded persons, 2,179 were 
males and 2,112 were females. 

Description. 

Physical and Mental Characteristics. — The child is father to 
the man, and in the main the physical and mental characteristics 
of the feeble-minded adult are similar to those of the mentally 
defective child ; but a few points of difference must be noticed. 

With regard to their physical condition, the anatomical stig- 
mata of degeneracy of course persist, whilst defects of stature 
and general development tend to become even more noticeable 
as the years advance, in comparison with the normal adult. On 
the other hand, a certain amount of improvement of function 
has taken place, so that the bodily nutrition is better, and 
the proneness to ailments not nearly so marked. Nevertheless, 
the expectation of life in the feeble-minded is decidedly less 
than in the ordinary population. Improvement is also usually 
seen in nerve action, and although the diminution or excess of 
movement which characterized the child is still a feature of the 
adult, and the balance and carriage of the body are often 
still clumsy and ungainly, the adult has, with the practice result- 
ing from years of experience, gradually acquired a certain amount 
of muscular control. As a consequence, the tricks, habits, and 
often marked inco -ordination of the child are less frequently 
seen in the adult. 

Similarly with the mental condition. A certain amount of 
savoir-faire is acquired by experience, and mental action generally 
may have been considerably improved by special training. But 
the capacity of these persons only extends to the things with 



Feeble- Mindedness in Adults 149 

which they are familiar, and they cannot rise to any work or 
circumstances outside their daily routine. They still show the 
same lack of observation and reasoning power, they have little 
ability to generalize or to apply their limited knowledge to new 
conditions, and their ideas still retain much of the crudity of 
childhood. It results from this that, although the feeble-minded 
adult may be, and often is, capable of useful employment of a 
routine nature under supervision, he is as a rule incapable of 
steering his own course, or even of providing for himself without 
some assistance. And when contrasted with a normal indi- 
vidual of similar age, his lack of mental capacity is even more 
prominent than in the case of the defective child. 

On the whole, I think that the foregoing description is applic- 
able to the bulk of the feeble-minded ; but it must be remem- 
bered that there are many degrees, and that no account can be 
given which would fit every member of the class. This descrip- 
tion is probably too nattering to some of the more pronounced 
defectives ; on the other hand, to the highest types of all such 
an account may be somewhat unfair, for many of these are 
tolerably well grown and developed, and show little indication 
of their weakness if they are not scrutinized too carefully. 
Those of this mild grade belonging to the upper and wealthier 
classes — for poverty has no monopoly of feeble-mindedness — 
do not usually find the daily round of society beyond their 
capacity ; they even marry or are given in marriage, and it is 
only when a situation arises which calls for management and 
judgment that their defect becomes patent. So long as they 
are under supervision they pass muster, but once let them take 
the reins and chaotic disaster speedily results. 

It is, however, rather in the matter of character that the 
greatest difference exists between the grown-up and juvenile 
feeble-minded. Ordinary persons approximate to one common 
type much more in childhood than in adult life, and although 
individual differences are observable from the first few weeks 
of life, they become much more pronounced about the age 
of puberty. So it is with the feeble-minded. The advent of 
puberty often sees the evolution of habits and propensities which 
have the greatest effect upon the future life, and which have 
hitherto been latent. Possibly to a considerable extent these 



150 Mental Deficiency 

may be dependent upon the early environment and training, or 
absence of training ; but heredity often plays an important part, 
as in the ordinary child. Whatever their origin, the mental 
defect and lessened power of control of these persons tend to 
bring these habits and propensities into extreme prominence. 

These propensities are many and varied, and from the point of 
view of administration they demand the closest attention. 
Indeed, I would go so far as to say that, in dealing with the feeble- 
minded, there could be no greater administrative blunder than 
to treat mental defect in the abstract, and pay no regard to these 
peculiarities of the individual. Some feeble-minded persons are 
placid, well-behaved, and industrious ; others are perfectly harm- 
less, but possess pronounced wandering proclivities ; others are 
exceedingly facile ; whilst yet others have a strong predisposition 
to insanity or crime. On the whole, I think that all of them may 
be divided into two main classes, according as their mental equi- 
librium tends to be stable or unstable, and these we may briefly 
describe. 

Feeble-minded of Stable Mental Equilibrium. — Many feeble- 
minded persons are quiet, placid, inoffensive, and good-natured 
individuals who go on their way comparatively unmoved by the 
happenings of life. They are not insensible to pleasure, and 
they evince a certain amount of delight, just as would a child, at 
a theatre, a circus, the sight of a company of soldiers, or the like. 
They are also conscious of, and affected by, praise, rebuke, or ill- 
treatment ; but their joy or sorrow is neither excessive nor of 
long duration, and their general demeanour is that of happy 
placidity. The mental constitution of such persons is in striking 
contrast to that of the class we shall next consider, and they may 
be appropriately designated as of stable equilibrium. I can give 
no precise figures, but my impression is that this type comprises 
about 30 to 40 per cent, of all the feeble-minded. Owing to the 
present lack of organization for providing these persons with 
suitable employment, a considerable number of them are idle, 
and spend their time roaming the villages and country lanes ; 
but most of these will cheerfully carry a parcel or do any odd 
jobs they may be asked to do, and those for whom continuous 
employment is found prove themselves to be steady, industrious 
workers. Illustrations of this type are shown in Plate IV. 



Plate IV. 





To face page 150.] 



Feeble-Mindedness in Adults 151 

In the country a certain number of them are employed upon 
the land in some simple capacity, such as helping with the 
hay or corn, the plough or roots, scaring the birds, or bringing 
up the cows ; and although they cannot be trusted to do the full 
work of an agricultural labourer, they often take the place of a 
boy to the satisfaction of their employer, and they are quite 
worth their keep and the shilling or two a week they receive. 
It is probable that most moderate-sized villages possess at least 
one of these " softies," " naturals," " dafties,"or " not exactlies," 
as they are called ; and although they are at times made fun of by 
the urchins of the place, they are not, as a rule, unkindly treated. 
In the towns, on the other hand, this type is not nearly so common. 
Such persons may occasionally be seen selling newspapers, dis- 
tributing bills, hawking firewood, or doing odd jobs for some 
charitably disposed person ; but the increased competition of 
town life is decidedly against them, and they rapidly tend to be 
squeezed further afield or to gravitate into the workhouse or 
some charitable institution. 

The life of these persons is one of conformity to habit, and not 
to ideals. They rarely think of, much less make plans for, the 
future ; and the few who have vain imaginations as to what they 
would like to do or become are lacking in the necessary intelli- 
gence or will to direct their actions accordingly. Indeed, one of 
the most pronounced features of the feeble-minded person is his 
utter lack of purpose. If given work and told exactly what to 
do, he may often be trusted to do it ; he may even acquire the 
habit of performing the same task day after day, year in and 
year out, without supervision. But the work must be strictly 
of a routine nature, for he would be quite unable to cope with 
any unforeseen occurrence. And should he lose his employment, 
he is incapable of any strenuous attempt to seek more. To use 
a homely phrase, we may say that the bread of these persons 
must be put into their mouths. 

The following is a fairly typical illustration of this stable type 
of high-grade feeble-mindedness : 

A. C. is a man of twenty-two years, although he looks only 
about seventeen. He went to an ordinary elementary school, 
and was in the sixth standard when he left ; but his school- 
master tells me that he was only moved up each year on account 



152 Mental Deficiency 

of his size and age, and that his scholastic attainments were really 
only equal to Standard III. During the two years following 
school he had several situations, mostly as errand-boy, but he 
was discharged from each place in turn on account of general 
incompetency. Then he was taken, largely from philanthropic 
motives, into a printing-office, and there he has remained until 
the present time. His work is purely mechanical, and consists 
in helping a man with the machine, carrying bales of paper, and 
so on. He began with a wage of nine shillings weekly ; this 
has been increased, and he now has a standing wage of eleven 
shillings, but he often puts in overtime, and he usually earns 
about thirteen shillings. He lives at home with his parents, and 
he gives his money to his mother, who allows him a shilling 
weekly as pocket-money. When clothing or boots are required, 
his mother buys them, and, in fact, he is treated exactly as a 
child. He is perfectly happy and contented with his lot, and 
has no ambition to be other than what he is ; but it is difficult 
to say what is going to happen when he has no home to go to 
and no parents to look after him. I asked him if he had ever 
thought of getting married. He said : " No." I asked him if he 
ever kept company with anyone. He said he did for a time, 
and used to " walk out " with a girl every night. To my ques- 
tions as to what he used to say to her, he' said : " She used to ask 
me how I was getting on at my work. I said : ' Pretty fair.' I 
used to ask her how she was getting on at her work. She said : 
' All right.' " There do not appear to have been many love- 
passages, for he admits that he never kissed her. After six 
months the maiden tired, and she now walks out with one of his 
more enterprising mates. This youth once conceived the desire 
to join the Volunteers, and applied to the local non-commis- 
sioned officer. The Sergeant-Major, a shrewd man and a good 
judge of men, rejected him, and, when I asked if he didn't come 
up to the physical standard, said : " His body was all right, sir ; 
but he had too little brain-pan." He has a few stigmata, can 
read and write tolerably well, and can do simple sums ; he can 
also copy drawing very creditably, but he has little other know- 
ledge. After a good deal of consideration, he told me that history 
was " what happened before," and that geography was " about 
towns and rivers," but he has no historical or geographical 



Feeble-Mindedness in Adults 153 

knowledge. I asked him which was the first war that he learned 
about. After much cogitation he said : " It was near Trafalgar 
Day. It was when Nelson fought. He defeated the Spaniards." 
On being asked how long ago that happened, after a very long 
pause he said : " From then to now, do you mean ?" and, on my 
replying in the affirmative, said : " About seven hundred." His 
knowledge of geography was of the same order, and although 
he told me he had got a Sunday-school prize, to my query as to 
who God was he replied, after much thought : " The Son of 
man." 

I am acquainted with a feeble-minded man, John C , who 

has steadily and industriously cracked stones by the roadside for 
the past forty years. He lodges in the village with a labourer 
and his wife, and the latter wakes him in the morning, gives him 
his breakfast, makes his dinner into a parcel, and sends him off 
to work. When dinner-time comes, which he knows by seeing 
the labourers in the field leave off work, he eats the contents of 
his parcel. Sometimes John feels hungry, and eats it before. 
About five o'clock, which he also knows by the passing of the 
postman, he leaves off work and returns to his lodging. He has 
his tea, sits by the fireside until about eight, and then goes to 
bed. Occasionally John has been known to get tired of work 
and come home in the middle of the afternoon ; but such lapses 
are very rare, and on the whole he is exceedingly methodical 
and industrious. He knows that Sunday is a day of rest, but 
he must be told that it is Sunday, or he would go to work as 
usual. John's landlord once played him the prank of not telling 
him it was the Sabbath, and he went off as usual without any 
suspicion. But he had intelligence enough to notice the trick 
on passing through the village, by seeing that the shop was 
closed, and he came back vastly amused at what he thought 
was a fine mistake. He receives a few shillings each week from 
the Rural District Council, and this he faithfully carries to his 
landlady, who allows him a penny now and then when he asks 
for it. This, however, appeared to be seldom, for John seems 
to be in the happy condition of having all his wants supplied. 

One might describe many cases similar to these, both in town 
and country ; but it is unnecessary. They illustrate very well 
the stable type of feeble mind, and the manner in which routine 



154 Mental Deficiency 

work may be performed by this class with comparatively little 
supervision. I have even known several who have served their 
time in the army. It is necessary, however, to remember that 
their intelligence is limited, and that these persons must not be 
entrusted with work beyond their capacity, or the result may be 
disastrous. I may mention a striking example of this which 
occurred in the case of a feeble-minded woman resident in a work- 
house. Her daily occupation was washing in the laundry, which 
she did very well. But one day the charge-nurse of the maternity 
ward most unfortunately gave her a baby to wash. She did so 
in boiling water, with, it need hardly be said, a fatal result. 

But although these persons are capable of useful employment, 
they have no capacity to lay out the money they earn or to 
manage their affairs. Food, clothing, and shelter must be pro- 
vided for them, just as with children, and in the absence of some 
one to look after them they soon get into a most woeful plight. 

As an instance of their general " incapacity to manage their 
affairs with ordinary prudence," I may mention the case of a 
woman I met in a small village in Somerset. She was the 
daughter of the village shopkeeper, and upon her parents' death 
had inherited sufficient cottage property to keep her in comfort 
for the rest of her life. Unfortunately, however, no one was 
appointed to look after her, and so it came about that little by 
little she was diddled, by relatives and acquaintances, out of 
every penny she possessed, and when I saw her she had been 
taken in out of pity by the wife of a labouring man, who received i 
a few shillings weekly from the parish to look after her. 

Throughout the country there are hundreds of feeble-minded | 
persons, many of them gentlefolk by birth, in like case. As long 
as they are provided with a home, and have parents or relations 
to generally supervise them, things go well. They perform little 
household and outdoor duties, take up simple hobbies like poker- 
work, stamp-collecting, and amateur cabinet-making, and enter 
into the ordinary social amusements of the class to which they 
belong. Most of their friends recognize that they are not quite 
" all there," but they often pass muster with casual acquaint- 
ances. But once let them get away from the parental apron- 
strings, and assume the responsibilities of an independent 
existence, and their want of mental capacity is fully revealed, 



Plate V. 




^ T 







C <D 

O c 

T3 '55 



1.1 



^ y»t^ ^rt^ 1 54. ] 



Feeble- M in dedn ess in Adults 155 

and results in their complete undoing. In the case of feeble- 
minded girls this general inability to take care of themselves 
is particularly evident, and demonstrates in the most forcible 
manner the urgency of the need for their protection. 

Lastly, it may be said that, although the religious and moral 
sense of these persons is rarely of a high order, most of them are 
conscious of the difference between right and wrong, and of the 
fact that they have certain obligations towards their neighbours. 
A goodly number, indeed, are quite capable of understanding 
simple theological doctrine. 

Feeble-minded of Unstable Mental Equilibrium. — It is not, per- 
haps, surprising that the mind which is defective should also lack 
balance, and in a very considerable number of feeble-minded 
persons — indeed, I think in the majority — the mental defect is 
accompanied by more or less mental instability. This may not 
become evident until the physiological epochs of puberty or 
adolescence have been reached, and one meets many cases in 
which the whole disposition of the individual seems to undergo 
an alteration at these times ; but often the condition can be 
detected in childhood, and is shown by the fits of ir ritability , 
excitement, moroseness, suJkiness, or so-called " bad temper," 
which are present in a ^considerable number of "defective 
children. 

The degree of instability varies much in different individuals, 
and at different times in the same individual. Some are simply 
giggling, emotional, and impulsive, liable to sudden fits of way- 
wardness, but readily controllable, and on the whole capable of 
doing useful work. In these the attack has much of the character 
of an epileptic seizure. I have known one of this type, a silly, 
giggling, weak-minded girl, to plunge her head into a pail of 
water without the slightest hesitation when the suggestion was 
made to her. I have known another to set fire to a hay-rick, 
and another to dash her hand violently through a window-pane 
in a sudden access of temper. And yet all of them, on the 
whole, were good, willing workers and in fairly constant 
employment (see Plate V.). 

In others, however, the instability is more persistent, and the 
person is so changeable and undependable that continuous em- 
ployment is out of the question unless the closest supervision can 



156 Mental Deficiency 

be maintained. Many of these are girls, and the following case 
is a very good example of the type : 

Alice S is a feeble-minded girl of nineteen years. She is 

the daughter of working people, and went to the Board-school 
until she was fourteen years of age ; but her schoolmistress says 
she could make nothing out of her, that when she left she could 
only just read and write, and that she was " always spiteful, 
untrustworthy, and a regular nuisance." Upon leaving school 
a situation as day-girl was found for her. She ran away on the 
third day, and refused to go back. Then she got another place, 
but only stayed a week, as her mistress " could not put up with 
her ways." This went on for over two years, during which time 
she had no fewer than twenty- two situations. She was then 
sent to a laundry training home, and here for the first few weeks 
she was much quieter, and it was hoped that she would settle 
down into good habits. But the hope was futile. The matron 
found that not the slightest dependence could be placed upon 
her word, that she was dirty in her person, lazy, an incurable 
pilferer, and up to the most cunning tricks to annoy and irritate 
her companions. She was therefore sent home again. Here 
she remained for some months, doing no work, and causing her 
relations endless trouble and worry. On several occasions she 
was brought home by the police, and finally, within a year of her 
return from the training home, she was admitted into the 
maternity ward of the workhouse. It was there that I first saw 
her, and although she was a strong, active girl, and quite capable 
of doing domestic work, she was nevertheless so erratic, impulsive, 
and generally irresponsible, that nothing could be made of her. 

The following is a somewhat similar case : 

F. H., a feeble-minded man twenty- three years of age, having 
the appearance of a youth of seventeen or eighteen. He is 5 feet 
in height, and weighs 7J stones, is thin and ill-nourished, and 
has numerous stigmata. He is extremely unstable, at times 
being quiet and well-behaved, at others noisy, restless, talking and 
laughing to himself, and interfering with those around him. In 
one of these fits he attacked his brother with a hammer. He has 
had several situations, but has been unable to keep any of them. 
He can read, write, and do simple sums, and although, when 
questioned, he seems to have a fair knowledge of many common 
things, he is too defective and unstable to turn his knowledge to 



Feeble-Mindedness in Adults 157 

any account. He is a ready talker when in the mood, and gives 
a very plausible account of himself. He says he is " what you 
call an orphan, and only has his brothers to be acquainted with 
now. Was in the sixth standard when he left school, and used 
to do reading, writing, arithmetic, composition, and geometry ; 
was never at the top of the class — master used to think him a 
backward boy. It was writing from memory that was his worst 
subject ; memory was always bad. Once got a prize for religious 
catechism. Was in the boys' home learning printing for nine 
months, but they gave him the sack because he accidentally 
spoilt a special job. Has had other chances, but never seemed 
to get on very well. If they would only give him another chance 
he would do his very best. Several of the other people have 
interfered with him, and then, of course, he has to take care of 
himself. One of his masters told him he would get on better if 
he didn't allow himself to be put on, and looked after himself 
more." 

Lastly, in another group of these unstable feeble-minded a 
condition of actual insanity is present ; but as this is a com- 
plication of some importance, I shall deal with it in a subse- 
quent chapter. 

As already remarked, it is likely that a good deal of the mental 
instability of these persons is the result of an unsuitable environ- 
ment in early life, and it is probable that careful and firm training 
during childhood might do much to prevent it. I am certain, 
however, that it is often inborn, just as is that instability of 
mental constitution in the " normally " developed which is so 
often the precursor of insanity ; indeed, I am inclined to look 
upon all feeble-minded persons of this type as potential lunatics. 

It is easy to understand that criminal actions may be committed 
by such persons, and there is no doubt that they constitute the 
great majority of feeble-minded criminals. Also, although prob- 
ably not so often the case to-day, there is little doubt that in 
years gone by those of the facile type were frequently made use 
of to further the schemes of the professional law-breaker. It is 
not merely that these persons are incapable of appreciating the 
consequences of their actions — for that might be said of most 
of the feeble-minded — it is rather that their defect is accom- 
panied by such a general instability of mind that they are 
either peculiarly susceptible to any suggestion, or are liable to 



158 Mental Deficiency 

flare up for the most trivial cause. The train is already laid ; 
it is only the spark that is needed. It is obvious that feeble- 
minded persons of this type are much more likely to come into 
contact with the authorities than are the harmless, placid indi- 
viduals previously described ; and, as a matter of fact, a very large 
number of them are inmates of our workhouses, prisons, asylums, 
or charitable homes. Still, the number at large throughout the 
country is not inconsiderable, as is shown by the investigations 
of the Royal Commission. 

To this account of the chief characteristics of high-grade amentia 
we may add that, although defect may be especially pronounced 
in some one particular faculty, there is no one single defect which 
is typical of the feeble-minded ; consequently there is no single 
psychological test of this condition. Deficiency of some kind or 
other is always present in the highest mental faculties, but the 
nature of this is subject to considerable variation. In many 
persons there is an utter inability to acquire any kind of book- 
learning, although they may use their hands with considerable 
dexterity. On the other hand, there are those who possess a 
remarkable aptitude for acquiring certain forms of knowledge, 
but who are so simple and childish as to be utterly incapable of 
providing for their daily wants. Others, again, as will be seen 
in treating of moral defectives, have a degree of cunning and 
intellectual quickness of a certain order which is at times astonish- 
ing ; whilst yet others are stolid, indifferent, and entirely negative. 
It is thus seen that mental defect cannot be looked upon as simply 
a lower grade of the normal, but as a distinctly pathological con- 
dition in which defective is accompanied by irregular develop- 
ment. Considered from the standpoint of practical daily life, 
the essential characteristic of this class is that, whereas the 
ordinary person, whether quick or dull witted, profits by his 
experience, and learns bit by bit to take care of himself and to 
adapt his behaviour to the exigencies of the moment, the feeble- 
minded person does not. The defective and irregular develop- 
ment of his mind have combined to bring about a lack of that 
quality which is so hard to define, and yet so essential to success 
in life — common sense. In any doubtful case, therefore, the 
diagnosis must rest not only upon the examination as to the 
present mental attainments, but also upon a careful consideration 
of the previous history and general conduct of the individual.' 



CHAPTER X 

IMBECILITY 

Definition. — The term " imbecility " (Latin imbecillus, doubt- 
fully derived from prefix im for in, and bacillus, a staff — one with- 
out a stay or support, hence feeble, helpless) is applied to the 
medium grade of amentia ; and although there are many mem- 
bers at the top and bottom of this grade whose condition closely 
approximates to the feeble-minded and the idiots respectively, 
nevertheless it is one which, as a whole, has tolerably well-defined 
features. The imbeciles stand above the idiots in the possession 
of an instinct and capacity for self-preservation, but below the 
feeble-minded in their inability to perform sufficient work to con- 
tribute appreciably towards their support. They are defined as 
" those persons who, by reason of mental defect existing from birth or 
from an early age, are incapable of earning their own living, but are 
capable of guarding themselves against common physical dangers." 

Number. — I estimate the total number of imbeciles existing in 
England and Wales on January i, 1906, at approximately 25,096 
persons, corresponding to 073 per 1,000 of the population. The 
class is thus nearly half as numerous as the adult feeble-minded, 
and about three times as numerous as the idiots. The inquiries 
of the Royal Commission show that imbeciles, both absolutely 
and relatively, are more prevalent in rural than in urban and 
industrial areas. 

Sex. — There is a slight preponderance of the male sex, and out 
of 1,807 imbeciles discovered by the Royal Commission 959 were 
males and 848 females. 

Description. 

All imbeciles come within the terms of the definition just given, 
in that they are possessed of wit sufficient to understand and 
avoid the common physical dangers which threaten life, but 

i59 



j6o Mental Deficiency 

insufficient to enable them to pursue any continuous occupation 
in such a manner as to provide for their sustenance. But whilst 
they all agree in these common characteristics, a certain propor- 
tion present such marked physiognomical, and often mental, 
peculiarities as to form distinct clinical varieties. These varieties 
will be described in subsequent chapters, the general account ; 
which will here be given of imbeciles and idiots, as also the pre- 
ceding account of the feeble-minded, referring to the simple type 
(the " genetous " group of Ireland), to which the great majority 
of these persons belong. (See Chapter V., " Classification.") 

Physical Condition.— In a small number of persons suffering ( 
from imbecility of the secondary form (in which the defect is 
accidental and symptomatic of some acquired disease of the I 
brain), the features, stature, and general bodily development 
may not differ from those of a healthy person. But these cases 
are not numerous, and in the great majority of simple imbeciles 
of the primary form the bodily as well as the mental condition is 
obviously defective. 

Occasionally gigantism is seen, but as a rule the stature is 

several inches less than that of the normal person. In addition, 

the body is ill-formed, its balance and carriage are ungainly, 

there are many oddities of walk and bearing, whilst stigmata of 

degeneracy are both numerous and prominent. The expression 

of the imbecile is usually in itself sufficiently striking to attract 

attention, varying from a stolid vacuity to a fatuous and childish 

smile or a look of sly cunning. Disturbances of physiological 

function are common. Various degrees of paralysis occur in a 

certain proportion of cases, and probably about 40 per cent, of all 

imbeciles suffer from epilepsy. On the whole, the bodily con- 

dition is so distinctive that even the casual observer has little 

difficulty in dubbing one of this class a " daftie " or " natural. 

(See Plates VI., VII., and VIII.) 

Mental and Nervous Condition.— In some imbeciles one or more 
senses are markedly defective ; in others there is an increased, 
and even extraordinary, delicacy of a particular sense ; in the 
majority, however, sensory perception is obtuse, and a condition 
similar to, but decidedly more aggravated than, that in the 
feeble-minded is present. The tenacity of memory for isolated 
events does not appear to be diminished, but the range of memory 



Plate VI. 





To face page 160.] 



Imbecility 161 

is decidedly inferior to that of the normal person. Probably this 
is largely the result of a defective power of association. Spon- 
taneous attention is sometimes diminished. Although many of 
these persons can be habituated to perform routine work of a 
simple kind, they are quite incapable of any task necessitating a 
sustained effort of voluntary attention. A few of the milder 
types show some evidence of imagination, but the majority are 
lacking in this faculty. Where the feeble-minded person will 
invent plausible excuses to escape punishment for his misdeeds, 
the imbecile will simply lie without embroidery. Many have 
some capacity for imitation, and at times this may be educated 
sufficiently to enable them to perform a certain amount of useful 
work ; but they readily tire, and in most cases the value of the 
work done is not worth the supervision it entails. Occasionally the 
imbecile is markedly defective in volition, but this is by no means 
always the case, for some of these persons have exceedin gly,, 
st rong dg sires, and are capable of no little strength and cunning 
to obtain their ends. It is often easier to le ad tha n to drive 
an imbecile, and some of them are particularly amenable 
to suggestion. It is, however, in reasoning capacity that 
the most marked difference is seen between this class and the 
feeble-minded. The latter person, although very defective, is 
still capable of simple mental comparisons, and of arriving at 
simple judgments ; but the imbecile is usually quite incapable 
of this. 

Abnormalities of movement are of very common occurrence. 
In the apathetic type there is a general diminution, whilst in 
those of the excitable form all movement tends to be excessive. 
These excitable imbeciles are constantly chattering, running 
about, and generally interfering with everybody and everything. 
Some of them are violently aggressive, and a few become actually 
insane. Defects of co-ordination are both commoner and more 
pronounced than in the feeble-minded. Most imbeciles can 
speak, although they can only form simple sentences, and their 
vocabulary is a meagre one. The development of the faculty of 
speech is invariably late. A few are exceedingly voluble in con- 
versation, but the matter is childish and inconsequent. Defects 
of pronunciation are numerous. Some imbeciles can read simple 
sentences, and a few learn to add and subtract upon their fingers, 

ii 



1 62 Mental Deficiency 

or by means of beads, but the scholastic acquirements of the class 
as a whole are of a very low order. 

Like the feeble-minded, imbeciles are divisible into two chief 
types — the apathetic or stable and the excitable or unstable. 
Accordingly, they differ greatly in their disposition and general 
behaviour. Some are harmless, inoffensive, and well-behaved ; 
but others are just the reverse, and require to be under constant 
observation. These latter are often sly and cunning to a degree, 
always in trouble, and possessed of pronounced immoral and anti- 
social tendencies. Some are clean in habits, modest, and possess 
a tolerable sense of decency ; others are absolutely destitute of 
any idea of shame or modesty. Masturbation is very frequent 
in imbeciles of both sexes, and many of them will practise it in 
the most open and outrageous manner. Some imbeciles show 
unmistakable signs of jealousy, and a considerable number are 
exceedingly vain, not only of their dress and general appearance, 
but even of their mental attainments. 

The following cases illustrate the chief features of simple 
imbecility : 

C. H., a fat, smiling man, forty years of age, who has been in 
the asylum since boyhood. He has no friends living, and, beyond 
a note in the case-book to the effect that there is insanity on the 
father's side, there are no particulars. He understands and can 
carry on a simple conversation, but he cannot read or w r rite, and 
has no conception of figures. He can, however, appreciate pic- 
tures, and will laugh immoderately at anything funny. He is 
good-tempered and obedient, but a perfect glutton, and will 
devour any scraps he comes across. He is too defective to be ! 
entrusted with any work without supervision, but is very willing 
and spends most of his time with the gardener in the grounds. 

/. F., male, twenty years old, is the last born of a family of 
seven, of whom three died in early childhood (one of convul- 
sions) ; two are said by the mother to be "all right," whilst 
another is mentally defective. The father is alive, but has been 
insane in an asylum twice ; one of his brothers died in an asylum. 
The mother is alive, but in delicate health. Two of her sisters 
and one brother died of consumption. 

James has always been " delicate " ; he did not stand until 
turned two years, and did not walk until his fourth year. He was 



Plate VII. 




B 9 






u p 
03 b/) 

I 




To face page 162.] 



Imbecility 163 

over five before he spoke, and even now his vocabulary is limited 
to about a dozen words. These he uses very sparingly, and it 
is rarely that he can be got to reply to questions, although he 
understands a good deal of what is said to him. He never 
attended school, as the head-mistress refused to have him. He 
remained at home quite unoccupied until fifteen years of age, 
when he became unruly and more than his mother could manage. 
Since then he has been in the asylum. 

He is a short, stumpy, fat youth, with coarse features, large 
outstanding ears, and a typical imbecile expression. He has a 
high saddle-shaped palate and very irregular and malformed 
teeth ; but these cannot always be demonstrated, as he usually 
obstinately refuses to open his mouth. Cranial circumference, 
22j inches. There is no paresis, but he is clumsy and heavy in 
all his movements. There is no marked defect of the special 
senses, but, owing to his usually taking not the slightest notice 
of any question addressed to him, he has been thought to be 
deaf. This, however, is not the case, as I have succeeded in 
getting him to turn round at the sound of a whistle, and have 
once or twice managed to get him to execute a simple com- 
mand. He seems to have little idea or care as to where he is, is 
apparently unconscious of the flight of time, and is, as a rule, 
perfectly stolid and inoffensive. But occasionally he has a noisy 
outbreak, and then he will rush about the ward grunting, yelling 
and interfering with anyone whom he meets. I saw him one 
day munching biscuits out of a paper bag which had been 
brought him by his mother. I intercepted each biscuit on its 
way from the bag to his mouth. He did not seem to mind, and 
placidly got another out of the bag. When I had succeeded in 
getting them all, he stood still in a vacant, perplexed sort of way, 
without seeming to understand or care very much, and after a 
time he walked away. 

H. C, female, seventeen years ; is the fourth of a family 
of eight, three of whom died in infancy ; insanity and epilepsy 
on father's side. No others are mentally affected, but mother 
says they are all delicate. The patient never seemed the same 
as the other children from birth, and did not walk until her 
fourth year. She has never talked properly. 

She went to school for several years, but never learned any- 

11— 2 



j6 4 Mental Deficiency 

thing and finally the mistress said she had better not come any 
™ore' Se has'since been at home. She understands a good 
Teal of what is said to her, and can execute simple command 
sucn a to shut the door or fetch a chair. She can answer simple 
cuesUons in monosyllables, but her articulation is so defective 
as to he unintelligible to a stranger. She has no idea of number 
and everything is " two." She has no knowledge of letters, but 
can ma2 strokes and ciphers on a slate. She also knows the 
"of fhe common objects of the ^^Vv^^ 
is quiet, obedient, and good-tempered. She is not actively 
destmct ve, but will always pick a patch off her clothes if th y 
nave been mended, and her chief joy is to ha«ap^« 
riven her to fray out. She cannot wash or dress herself, but 
fin feed with a Ipoon, and is of clean habits. Her chief pecu 
ifarity seems to be that, as soon as she takes the first mouthful 
offood she invariably goes to sleep, and has to be wakened to 
finish her meal. 



Plate VIII. 




~0 x 



2*6 
+3 c 




3j 
"x ft 

« C 

0) <u 






O x 
C x 

O P 

ft Sc 

< rt 



To /.ice page 164.] 



CHAPTER XI 

IDIOCY 

Definition. — In the idiots we see the third and lowest degree of 
defect, arid the mental deprivation in these persons is indeed such 
as to fully justify the term idios ( a person " private," " apart," 
or " solitary ") which is applied to them. 

The line between this class and the imbeciles has been variously 
drawn by different writers. Some would consider the presence 
or absence of speech as the criterion, but there are many imbeciles 
— and even feeble-minded — who cannot speak. Others, again, 
would use attention or volition, but these are not necessarily 
lacking in the idiot. If a line is to be drawn, and, if only for 
purposes of description, it is clearly a great advantage that we 
should have some means of differentiation, then I think that the 
absence of the instinct or power of self-preservation constitutes 
the most convenient one, and this we shall accordingly use. 

The idiot is therefore defined as " a person so deeply defective 
in mind from birth, or from an early age, that he is unable to guard 
himself against common physical dangers." 

Accepting this as the criterion, it is at once seen that idiots 
are divisible into two groups. In one of these the defect is so 
profound as to involve the fundamental organic instincts, and 
even that of sucking is 'absent. These are termed complete, 
absolute, or profound idiots. In the second group the primitive 
instincts are present — there is even some glimmering of mind — 
but there is not sufficient intelligence to understand and avoid 
the common physical dangers which threaten existence. These 
may be termed the partial or incomplete idiots. 

Number. — The number of idiots existing in England and 
Wales on January i, 1906, was, approximately, 8,654 persons, 

165 



1 66 Mental Deficiency 

corresponding to 0*25 per thousand of the entire population. 
The class is thus about one-third as numerous as the imbeciles, 
and comprises about 6 per cent, of all aments. As we have 
already seen, idiots are absolutely and relatively much more 
numerous in rural than in urban districts, and, taking areas with 
a similar incidence of total amentia, we find that there are often 
from four to five times as many idiots present in the former as 
in the latter situation. A similar variation of incidence with 
regard to environment has been shown to obtain with the imbe- 
ciles also, but the disproportion is much greater in the case of the 
idiots. 

With regard to sex, the inquiries of the Royal Commission show 
that, of 585 idiots existing in the 16 areas of the United Kingdom 
which were investigated, there were 303 males and 282 females. 



Description. 

Partial or Incomplete Idiocy. — Physical Condition. — The 
various anatomical and physiological anomalies present in the 
imbeciles, and to a somewhat less extent in the feeble-minded, 
reach their maximum in the idiots ; and the members of this 
degree consequently present an appearance which is in itself 
distinctive. Some of them are grotesque, but the majority are 
such stunted, misshapen, hideous, and bestial specimens of 
morbid mankind that they arouse feelings of horror and repul- 
sion rather than of levity. (See Plates IX. and X.) Paresis or 
paralysis is very often present, and this tends still further to aggra- 
vate their defective physical condition. In some cases this para- 
lysis is due to a non-development of the tracts of the cord ; but 
in the majority it is the result of disease or severe gross lesions of 
the brain or nervous system superadded to the original develop- 
mental defect, such as porencephaly, hydrocephaly, micro- 
gyria, localized atrophies, and anomalies of the internal ganglia. 
The paralysis may be slight or severe. It may involve a hand 
or foot, or be a complete hemiplegia or diplegia. Many of these 
creatures are in consequence chair- or bed-ridden. Occasion- 
ally the condition known as " scissor-legs " is seen, in which 
there is paralysis of both lower limbs, with dislocation of 
the hip-joints, so that the legs are permanently crossed like a 



Plate IX. 




u 




To face fage 166.] 



Idiocy 1 67 

pair of scissors. There was a very perfect example of this at 
Darenth Asylum a few years ago. The feature of most of these 
paralyses is that they are the result of lesions occurring before or 
shortly after birth ; consequently the limb involved is stunted in 
its growth and development. 

Epilepsy is very frequent in simple idiots, and occurs in about 
56 per cent, of cases ; various forms of tremor and athetosis are 
also frequently seen. 

Many idiots are extraordinarily voracious, and gulp down their 
food with such haste as to be in imminent danger of choking. 
It has more than once happened, where spoon diet has not been 
given, that tracheotomy has had to be performed for the removal 
of a lump of food from the larynx. In a few cases rumination 
is seen. Troublesome diarrhoea is a very common result of the 
gluttony of these persons. Ireland mentions two cases in which 
inordinate thirst was present, the patients drinking almost any 
kind of liquid in enormous quantities ; neither was diabetic. 

Most idiots are sterile, but this is not always the case, and in 
some sexual feelings are obtrusively evident. As a class they are 
unusually prone to disease and to early death, particularly 
from tuberculosis. 

Mental and Nervous Condition. — Defects of sensation are very 
common in idiots, and although morbid conditions of the end- 
organs of special sense are very frequent, nevertheless the lack 
of perception seems to be more often due to a central than to a 
peripheral defect. All the senses may be affected, but it usually 
happens that one is most so. We thus find some idiots particu- 
larly impervious to sounds, others to sights, tastes, or odours. 

It is difficult to test the memory of these persons, but on the 
whole I am inclined to think that it is usually in default. 
Imagination seems to be wanting altogether, but some of the 
milder types have a certain capacity for imitating the actions of 
those around them. Active attention is very deficient, but spon- 
taneous attention is by no means always absent. Such thoughts 
as exist must be of the simplest description, and limited to 
objects immediately present to their senses. They have no power 
of reasoning, and although a few can connect simple words 
with the objects to which they relate, the majority cannot do 
this. Idiots have to be washed, dressed, and fed like little 



1 68 Mental Deficiency 

children ; many of them are utterly inattentive to the calls of 
nature, but some can be taught habits of regularity and cleanli- 
ness in this respect. They are by no means lacking in energy 
and volition, and many of them apparently experience satisfac- 
tion in destroying anything they can get hold of ; but their energy 
cannot be directed into any useful channel, nor are they even 
capable of intelligent play. 

Tears are very rarely seen, but there is no doubt that some 
of milder degree are capable of the simpler emotions. They 
evince anger, passion, and fright, and some of them will run 
away with a look of alarm upon the entrance of a stranger. 
They seem to be absolutely lacking in any sense of right or 
wrong, and these ideas cannot be implanted in them. 

Speech is usually absent, although a few learn to articulate 
such simple monosyllables as man, cat, eat, etc., but none of them 
can form sentences. Their utterances mostly consist of in- 
articulate grunts, screeches, and discordant yells ; but there can 
be no doubt that these often express their feelings, just as do 
the cries of animals, and an observant physician or attendant is 
able by this means to discern whether they are satisfied or dis- 
satisfied, contented or annoyed, sometimes even to interpret 
their simple wants. It is noteworthy that, although quite 
unable to articulate, some idiots will hum a tune which they have 
heard, with tolerable accuracy. 

Movement is often abnormal in quantity and quality. In 
the apathetic type of idiots it is deficient, in the excitable ex- 
cessive. In both these forms co-ordination is usually very 
imperfect, and they are hardly ever capable of any delicacy of 
manipulation. In standing, walking, or running the same 
defect of co-ordination is seen. 

Apathetic and Excitable Idiots. — We have seen that the less- 
pronounced grades of defect are divisible into two classes accord- 
ing as they are of stable or unstable mental equilibrium ; the 
same is true of the idiots, some of these being apathetic, and 
others excitable. The former are mild, placid, inoffensive 
creatures who give little trouble, and who even evince a certain 
amount of affection for those who feed and attend to them. 
The excitable type, on the other hand, are passionate, violent, 
untrustworthy, and intractable. Many of them are so exceed- 



Plate X. 





To face page 168.] 



Idiocy 169 

ingly destructive that nothing is safe within their reach. They 
will destroy clothes, toys, picture-books, even furniture, and 
if left alone for a few hours, the probability is that they will either 
wreck the room or set fire to or seriously injure themselves in 
some way. I have seen several of this class in cottages where 
the only available means of curtailing their activities to a reason- 
able sphere of influence was to tether them to the table leg. 
Often they are exceedingly cruel to animals, and seem to ex- 
perience pleasure at the cries of their unfortunate victims. 

Those of this type who are chair-ridden still manage to 
find an outlet for their excitability in the almost ceaseless per- 
formance of automatic actions. Thus, some will spend the day 
turning the head from side to side or nodding up and down ; 
others rock the body to and fro, or beat upon the chest with 
the hand, often keeping time to the movement with a mono- 
tonous, inarticulate chant ; others unceasingly suck their 
fingers. These movements do not occur during sleep, and they 
are terminated by the advent of feeding-time or the entry of a 
stranger, although at times a visitor seems to stimulate them 
into still more violent activity. It is evident that they are 
attended with satisfaction, for the patients commonly resent 
forcible interruption, and resume the movements again the 
moment they are free. In a proportion of cases this condition 
of restless activity is not constant, but intermittent, and resembles 
the periodical outbreaks of maniacal excitement which occur in 
the milder aments. Such persons will rush about the room or 
dormitory uttering hideous screeches and yells. In moments 
of passion they will even hurl themselves violently against walls 
or floor, and in so doing often sustain serious injuries. But the 
process seems to be rather pleasurable than painful. Even in 
those of the apathetic type, the advent of puberty often ushers 
in a marked alteration of character and behaviour, and there 
are many idiots who, having been fairly manageable and in- 
offensive until this time, then become so destructive and un- 
reliable that the restraint of an institution has to be sought. 

The following are illustrative cases : 

E. /., female, age thirty-two years. A pronounced history of 
insanity and epilepsy on the maternal, and alcoholism on the 
paternal, side. Has been in the asylum since seven years of 



17° Mental Deficiency 

age. A repulsive-looking woman with a muddy, freckled face, 
coarse red hair, and numerous stigmata ; cranial circumference, 
21 inches. She can walk, but spends the day sitting in a chair 
turning her head from side to side, rocking herself to and fro, 
and biting her hands. She is of unclean habits and is unable to 
do anything for herself. She is quite deaf in the right ear, but 
listens attentively to the ticking of a watch held close to her 
left. She seems to have no knowledge of time or place, and 
apparently no understanding of anything said to her. But 
when the piano is played, she at once ceases her rhythmic move- 
ments and listens attentively. She cannot speak, but she will 
hum the tunes she has heard so well that they are readily recog- 
nized. As a rule she is harmless, but upon any attempt at 
examination she makes violent resistance and tries to bite, 
and she is at times spiteful and interferes with the other 
patients. 

A. D. P., female. Has been in the institution since childhood, 
but the family history is not obtainable, as there are no friends 
living. On admission she was unable to dress or feed herself, 
and had no apparent understanding of anything said to her. 
She showed no curiosity, no imitativeness, and no power of 
attention. Her habits were unclean, and she was constantly 
dribbling from her mouth. She was a voracious eater. She 
was unable to speak, but addicted to violent yells, often inter- 
spersed with a peculiar sound like the braying of a donkey. 
She was at times exceedingly violent, kicking, biting, and 
scratching the nurses and other patients indiscriminately, and, 
in fact, was generally a source of endless trouble to the whole 
ward. She remained in practically the same condition until 
thirty-five years of age, when she had an epileptic attack. From 
this time until her death she was subject to occasional recurrences 
of the fits, and she died at the age of thirty-six, of gangrene of 
the lung, resulting from the aspiration of a small portion of food. 
The cranial circumference was 20 inches, and there were numer- 
ous stigmata of degeneracy. 

On making a post-mortem examination, I found a very thick, 
dense skull with an absence of diploe. The brain was small, 
weighing 1,022 grammes, but, beyond being very simply con- 
voluted, there were no naked-eye anomalies. Microscopical 



Idiocy 171 

examination, however, revealed extensive imperfections of the 
cells of both brain and spinal cord like those already described. 

Absolute, Complete, or Profound Idiocy. — In this condition we 
see humanity reduced to its lowest possible expression. Although 
these unfortunate creatures are, indeed, the veritable offspring 
of Homo sapiens, the depth of their degeneration is such that 
existence — for it can hardly be called life — is on a lower plane 
than even the beasts of the field, and in many respects may almost 
be described as vegetative. They come into the world without 
even the hereditary instinct of sucking. As they grow up they 
have to be fed, and would die of inanition amid abundance of 
food were it not put into their mouths. If they are conscious 
of excessive heat or cold, they are devoid of any idea of the 
remedy. They respire, assimilate, and excrete, but they have 
no sexual instinct, and cannot reproduce their degenerate 
species. They may be capable of inarticulate cries, but they 
cannot speak. They possess the power of muscular movement, 
but locomotion is absent. They have eyes, but they see not ; 
ears, but they hear not ; they have no intelligence and no con- 
sciousness of pleasure or pain ; in fact, their mental state is one 
entire negation. The short existence of most of these creatures is 
spent in bed, where they lie huddled up in an ante-natal posture. 
They are hideous, repulsive creatures whom Nature permits to 
enter, but not to linger, in the world, and in their life and death 
are revealed the culminating and final manifestation of the 
neuropathic diathesis. 

Diagnosis. — The diagnosis of simple idiocy and imbecility can 
rarely present much difficulty by the time the child has attained 
to the age of five or six years. Even before that age, a careful 
consideration of the family history, of the general backwardness 
of development, and of the many indications of defective physical, 
nervous, and mental condition which should be apparent to 
the physician, although they may not be noticed by the parents, 
will usually suffice to make the nature of the case quite clear. 
The idiot or pronounced imbecile is usually either phenomenally 
passive or abnormally restless from the first few days after birth. 
In the one case he is inert, showing no tendency to suck or grasp, 



172 Mental Deficiency 

so that even the nipple must be held in his mouth ; no tendency 
to cry or to be attracted by any sight or sound ; no response to 
the caresses of his mother ; and, in fact, no spontaneity of any 
description. In the other case he is constantly crying, and 
refuses to be pacified ; he restlessly tosses about from side to 
side in his cot, and from time to time may have convulsions. 
In some of these cases the screaming and general rest- 
lessness are so constant that the parents will complain that 
the child never sleeps. With either of these conditions there 
are usually present various anomalies of anatomical develop- 
ment, and although I do not mean to say that the combination 
of stigmata with one or other of these unnatural states is patho- 
gnomonic of amentia, nevertheless it is extremely suggestive 
of that condition, and the probability is greatly increased should 
there be a neuropathic family history. Careful attention to 
these points will often enable a diagnosis to be made in the first 
or second year, and should prevent the physician deluding the 
parents with the vain hope that the child will " grow out of it." 
With the advance of each year the nature of the case becomes 
more obvious, for the progressive mental development of the 
normal child gradually leaves the ament farther and farther 
behind. 

Where some added complication or particular pathological 
process is present, as in the special varieties of amentia to be 
described in subsequent pages, the clinical appearance is still 
more characteristic, and a diagnosis may then be possible at an 
even earlier age. 



CHAPTER XII 

THE CLINICAL VARIETIES OF PRIMARY AMENTIA 

It is probable that nearly 90 per cent, of all aments belong to 
the primary group, and the majority of these, as already men- 
tioned, present no special distinguishing features beyond the 
anatomical, physiological, and psychological anomalies common 
to primary aments in general. These, which may be termed 
the simple variety, have been described in the preceding pages. 

A small proportion, however, present such special character- 
istics as to form distinct clinical types. The chief of these are 
the Microcephalics and Mongolians, and these will be described 
in the present chapter. We shall also briefly deal with some 
clinical subvarieties which are the result of superadded morbid 
complications. 

The Grecian, American-Indian, Negroid, and other ethnic types 
which have been described by some authors do not seem to me 
to possess sufficiently distinguishing features to merit special 
notice. 

MICROCEPHALIC AMENTIA. 

By the term " microcephalic " is usually meant a person whose 
skull is less than 17 inches in its greatest circumference. But in 
view of the fact that other persons, with a greater cranial measure- 
ment than this, present similar mental peculiarities as well as 
skull configuration, I am disposed to think that the criterion 
should be one of shape rather than size. Most members of this 
variety belong to the more pronounced degrees of amentia, and, 
if the test of measurement be the one adopted, they probably 
do not comprise more than about 5 or 6 per cent, of all aments. 
If, however, the milder cases be included, and the criterion be 
that of cranial shape, this number is considerably increased, and 

173 



174 Mental Deficiency 



probably reaches 10 or 12 per cent. Many of these latter are 
merely feeble-minded. 

Causation. — The condition is one which has attracted much 
attention, particularly from anatomists, and two views have been 
put forward as to its causation. The first of these is that it is 
an atavistic variation ; the second, that it is a pathological con- 
dition due to premature closure of the cranial sutures. 

One of the earliest advocates of the atavistic theory was Charles 
Vogt, of Geneva, who, in a paper published in 1867,* attempted 
to show that microcephaly was a reversion to a prehuman type. 
Many cases were examined, and most minute dissections made 
by accomplished anatomists on the Continent and in this country. 
Conclusive evidence was adduced in support of the view, and 
equally conclusive facts in denial of it. It was at a time when 
the evolutionary theory was attracting widespread attention, 
v and it was not to be wondered at that the curious appearance of 
microcephalics should cause them to be looked upon as instances 
of a reversion to a simian type. It is unnecessary to enter into 
the pros and cons of the argument ; it is sufficient to state that 
the fact has now been established, as a result of many examina- 
tions, that microcephaly is not an atavistic variation, but a 
pathological condition, and that these persons, although 
degenerate, are still human. 

The second theory, that microcephaly was due to a premature 
synostosis of the cranium, attracted hardly less interest. Bail- 
largerf seems to have been the author of this view, and he 
enunciated it on the strength of some apparently very definite 
statements by the mothers of microcephalic children, that at 
birth the anterior fontanelle was closed. These statements were 
corroborated by Baillarger's examination of some cases in which 
synostosis was present. But it has since been found that many 
microcephalics exist in whom the sutures are not closed ; in fact, 
such is the exception rather than the rule, and hence this theory 
is now discarded. In the instances in which bony union has 

* C. Vogt, Geneva, " Memoires snr les Microcephales cm Hommes 
Singes," 1867. On this subject see also " I CervellideiMicrocefali," Professor 
Giacomini, Turin, 1890 ; also an excellent chapter in Dr. Ireland's work. 

f Baillarger, Gazette Medicale de Paris, 1857, p. 482 ; also Cruveilhier, 
" Anatomie Pathologique Generale," Paris, 1876. 



The Clinical Varieties of Primary Amentia 175 

taken place, it is much more likely to be the effect than the 
cause of the arrested cerebral development. 

The real truth is that microcephaly is neither atavistic nor 
accidental, but the result of inherited blight, just as is amentia 
in general. In most of the cases which I have examined morbid 
heredity was present ; in fact, microcephalics usually come of a 
pronounced neuropathic stock, their brothers and sisters are 
often typical degenerates, and frequently one or more of them 
suffer from the same condition. They are simply the result of 
a more gross developmental arrest than that which obtains in 
the majority of aments. 

Pathology. — The characteristic of this condition is a hypo- 
plasia of the cerebral hemispheres, which is more particularly 
pronounced in the temporo-sphenoidal, parietal, and occipital 
regions, so that the posterior lobes of the cerebrum rarely suffice 
to cover the cerebellum. To this the peculiar " sugar-loaf " 
conformation of the skull is due. In most cases, although under- 
developed, the primary sulci may be traced ; but in some 
instances these are very imperfect ; in the majority of cases 
there is also a marked deficiency in the secondary gyri, so that 
the complexly convoluted aspect of the normal brain is entirely 
wanting. In addition, there is often localized agenesis of par- 
ticular areas, resulting in the condition described as " micro- 
gyria, " as well as gross developmental anomalies of the corpus 
callosum and internal ganglia. Not a few cases are complicated 
by some recent morbid process, of which the commonest are 
encephalitis and hydrocephalus. The cerebellum is smaller than 
the normal, but is not affected to anything like the same extent 
as the cerebrum. The hypoplasia nearly always involves the 
spinal cord, which is much thinner and shorter than normal. 
The parts most affected are the pyramidal tracts and columns of 
Goll, the anterior columns and direct cerebellar tracts somewhat 
less so. From the stage of development of the cerebral fissures, 
it is quite evident that the cause is one which has been at work 
before birth. Microscopical examination of these cases usually 
reveals a similar condition of irregular and imperfect develop- 
ment of the cells of the brain cortex to that already described. 
The anterior horn cells of the spinal cord also frequently show 
similar changes. 



176 Mental Deficiency 

The weight of the brain varies very much in these cases. The 
lightest on record is the one described by Dr. Sander, as men- 
tioned by Ireland, which only weighed 170 grammes (about 
6 ounces). A case described by Dr. Fletcher Beach weighed 
198-4 grammes, whilst the brain of the celebrated HJene 
Becker weighed 219 grammes. But these are somewhat excep- 
tional examples, and typical microcephaly may be present with 
a brain weighing several hundred grammes more than these. 
The normal weight, it may be remembered, varies from about 
1,100 to 1,400 grammes in the male (mean average, 1,374 grammes 
or about 48 ounces), and 1,000 to 1,300 grammes in the female 
(mean average, 1,244 grammes or about 43 ounces). 

In view of the extreme smallness of the brain in these persons, 
the question naturally arises as to the influence of size of brain 
upon intelligence. There is, no doubt, a brain weight and cranial 
circumference so small as to be incompatible with anything more 
than a state of idiocy, and Felix Voisin places this at 13 inches 
circumference. It is tolerably certain that with a cranial 
circumference of 17 inches the mental capacity will not range 
above that of imbecility, and it is probable that the adult whose 
cranial circumference is more than 2 inches less than the normal 
minimum will be feeble-minded. But beyond this we cannot go, 
and even these statements can only be considered as of general 
application. 

The average size of the skull in aments is decidedly less than 
the mean average of normal persons, although there are a few 
(excluding hydrocephalics) in which the normal measurements 
are exceeded. But even in aments, apart from extreme cases 
like those of microcephaly, there is no constant relationship 
between the amount of intelligence and the cranial capacity. 

The same is true of normal persons. The range of variation 
in the mentally sound is as much as 700 to 800 grammes (about 
26 ounces), and there have been even eminent men who have 
diverged from the normal to a greater extent than this. For in- 
stance, the heaviest healthy brain on record is that of Turgenieff, 
the Russian novelist, which weighed 71 ounces, whilst that of 
Gambetta weighed but 40*9 ounces. The brain of Napoleon was 
53 ounces, and that of Cuvier 58*3 ounces. In fact, a whole race, 
the ancient Peruvians, attained to a very considerable degree of 



Plate XL 




o s 

b/j .~ 
n) 

J! 8 

o C 






U 13 

8 13 

I 

CO 






ft) W 



J3 C 

P 

O (u 



zv? /«^ ^«^ 176 ] 



The Clinical Varieties of Primary Amentia 177 

social development and excellence in the arts with a mean 
average brain capacity of only 40-1 ounces. 

The fact is that intellect is dependent upon quality as well as 
quantity of brain, and although in many aments a quantitative 
defect is present, there is always a qualitative deficiency also. 
Accordingly it results that even in microcephalics there is no 
constant relation between size of brain and mental capacity. 

Description. — Physical Condition. — The two chief clinical dis- 
tinguishing features of this variety of amentia are the peculiar 
configuration of the skull and the (usually) very small stature. 
As a result of the cerebral hypoplasia, there is a marked 
deficiency in the frontal and occipital regions of the cranium, 
which in consequence shelves away in a curiously " sugar-loaf " 
or cone-like manner. This shape, by some termed oxycephalic, 
is always present in microcephaly, and, taken in conjunction with 
the receding chin, gives a very characteristic and bird-like ap- 
pearance to these creatures. (See Plates XL, XVIII., and XIX., 
In consequence of the diminished surface of bone to be covered, 
the scalp is nearly always extraordinarily thick and redundant. 
In some cases it is permanently thrown into a series of deep 
furrows running antero-posteriorly, a condition which was first 
described in this country by Dr. T. W. McDowall,* and which 
seems to be confined to microcephales.f In addition the hair 
is usually extraordinarily coarse and wiry, and on more than one 
occasion I have known the teeth of the clipper to be broken 
whilst the hair was being cut. 

As already remarked, the cranial circumference in these 
cases varies very much, and the diagnostic feature is one of 
shape rather than of size. There have been several cases re- 
corded in which the greatest circumference was 15 inches or 
under ; on the other hand, I know several typical microcephalics 
with a cranial circumference of 19 inches and more, and one whose 

* T. W. McDowall, " Abnormal Development of the Scalp," Journal 
of Mental Science, January, 1893. 

f Dr. McDowall was good enough to place a portion of the scalp of one 
of these patients, who died under his care, at my disposal for examination. 
I found a considerable thickening of all layers, the average thickness 
down to the roots of the hair follicles being from 4 to 5 millimetres, and 
this after hardening in spirit. 

12 



178 Mental Deficiency 

skull measures as much as 21 inches. It is to be remembered 
that the actual brain capacity is less than a mere circumferential 
measurement would suggest, by reason of the deficiency being 
chiefly in the upper parts of the skull. 

The second characteristic, that of diminished stature, is not so 
constant ; nevertheless, as a class, microcephalics are the smallest 
of the varieties of amentia, and many of them may be called 
dwarfs. Few of them grow to more than 5 feet, although " Joe " 
(described by Dr. Ireland) reached 5 feet 9 inches in his boots. 
But this is decidedly exceptional. 

In other respects microcephalics present the anomalies common 
to aments in general, and which have already been described. 
They rarely live to an advanced age (in this respect also I think 
" Joe " is unique, since he was sixty years old at his death), and 
the majority die of tuberculosis. 

Mental and Nervous Condition. — The intellectual capacity of 
these persons varies within very considerable limits, and we thus 
have microcephalic aments of each of the three degrees of 
deficiency. A considerable number are idiots, unable to do any- 
thing for themselves, unable to understand more than a few 
words, and incapable of speech. Others, and the majority, 
belong to the imbecile class, and are capable of understanding 
most of what is said to them, can say a few words, and can 
perform simple tasks. A few are merely feeble-minded. The 
case of " Joe " is probably the best example of the mildest 
degree of defect, for Dr. Ireland says that until after forty years 
of age he was apparently able to earn sufficient wages to main- 
tain himself. I know several typical microcephalics amongst 
mentally defective children attending special schools who can 
read, write, do simple sums, and who probably possess sufficient 
intelligence to earn their living under supervision ; and one woman 
of this type, with a cranial circumference just under 17 inches, 
is one of the most industrious inmates of a county asylum. 

The mental features common to most microcephalics are 
the absence of any sensory defect, a general vivacity, restless- 
ness and muscular activity, a considerable capacity for imita- 
tion, and, usually, an inability for sustained effort. In their 
perceptive faculties these persons often compare favourably with 
aments of considerably higher general intelligence, and many 



The Clinical Varieties of Primary Amentia 179 

of them not only have remarkably good hearing and sight, but 
extremely quick powers of observation. The restlessness is 
sometimes expressed by the performance of peculiar actions 
which have caused them to be likened to various animals. Thus, 
Lombroso describes a " bird man," a " rabbit man," and a 
11 goose man." Their power of mimicry is often very marked, 
and this, combined with their general alertness, causes them to 
be amongst the drollest inmates of the imbecile ward. There 
was a chattering, restless ament of this type at Darenth a few 
years ago, who was very pat in making remarks upon anything 
coming under his observation, and who was a source of endless 
amusement to the attendants by his witticisms concerning one 
of them in particular. Another boy, aged eleven years, with a 
cranial circumference of 15 f inches, was most adept in mimicking 
the various performers in the band. 

In disposition the majority are affectionate and well-behaved. 
Many of them, before training, it is true, are apt to be quarrel- 
some and difficult to manage, but they usually soon lose these 
propensities and become quite amenable to the discipline of an 
institution. 

The majority of microcephalics of the idiot degree suffer 
from a condition of general helplessness, which causes them to be 
unable to do anything for themselves, and many of the imbecile 
grade even experience considerable difficulty and unsteadiness in 
walking. This does not appear to be due to actual paralysis 
(although I have seen a few cases with typical spastic paralysis 
and increased tendon reflexes), but to an imperfect development 
of the tracts of the spinal cord. About half of them are subject 
to epileptic fits. 

In conclusion we may briefly cite the chief instances of this 
interesting condition which have been recorded.* 

Dr. Wilbur described (1857) an idiot aged twelve years, in the 
New York State Asylum, whose cranial circumference was only 
I3j inches. He was passionate, uncleanly in his habits, could 
distinguish a variety of forms and colours, knew the names of 
all objects in the schoolroom and about the house, and recognized 
a great number of pictures of objects. He made but little pro- 
gress in speaking, and after being in the asylum five years, 

* For these particulars I am largely indebted to Dr. Ireland's work. 

12 — 2 



180 Mental Deficiency 

though improved in many respects, he was found incapable of 
further progress, and was dismissed. 

Antonia Grand out was described by Professor Filippo Cardona 
of Milan (1870).* She was a typical microcephalic, with a cranial 
circumference of 15 inches ; her height was 49J inches ; and she 
died at the age of forty-one years. She had no sensory deficiency ; 
in fact, her hearing was very quick and her observation very keen. 
She understood what was said to her, and was able to converse. 
She had a good memory for persons and events, was of a sociable 
and decidedly amorous and erotic disposition, and much addicted 
to dancing. Although decidedly defective, she had sufficient 
intelligence to do simple domestic duties and to run errands ; in 
fact, considering the extremely small size of her brain, her 
intelligence was altogether remarkable. 

Helene Becker died of phthisis at the age of eight years, and a 
very careful and complete examination was made, and report 
published, by Dr. Bischoff of Munich (iS^J.f This girl was a 
low grade idiot ; she knew her own name, but was practically 
incapable of understanding anything beyond, although she knew 
when people were angry with her. Her speech was limited to 
one word. She was very restless, always moving her hands and 
arms and the upper part of her body. The brain weighed 
219 grammes. Another child in the family was microcephalic. 

The " bird man," a microcephalic with a cranial circumference 
of 15 inches, was described by Professor Cesare Lombroso (1873)4 
He was so named from a habit of chirping like a bird, hiding his 
head under his armpit, leaping on one leg, and stretching out 
his arms like wings. He was said to be wanting in touch, taste, 
and smell, was dirty in his habits, and given to coprophagy. 
Professor Lombroso also recorded two other microcephalics under 
the designation of the " rabbit man " and the " goose man," also 
the three brothers, Nicolb, Serafino, and Giovanni Cerretti. These 
were aged twenty-one years, thirteen years, and ten years, and had 
a skull circumference of 17I, 16J, and i6J inches respectively. 

The "Aztecs " were a pair of microcephalic aments, boy and girl, 
of American-Indian origin, who were exhibited all over Europe 

* D' Una Microcefala, Milano, 1870. 

f Anatomische Beschreibung eines mikrocephalen, 8 Jdhrigen Madchens. 

\ Rivista Clinica di Bologna, July and November, 1873. 



The Clinical Varieties of Primary Amentia 1 8 1 

and America for forty years, and who have been described at 
various periods by different writers, including Professor Owen. 
They were seen by Dr. Dalton when aged seven and five years 
respectively, and were described as being only able to repeat 
a few isolated words, but very excitable, vivacious, in almost 
constant motion, and full of curiosity. Their habits as regards 
feeding and taking care of themselves were those of children 
two or three years old. They were publicly married in London 
in 1867, but had no offspring. 

Freddy, who was under the observation of Dr. Shuttleworth 
for twenty years at the Royal Albert Asylum, died at the age of 
twenty-nine years, of phthisis. At the time of his death his 
height was 4 feet 8 inches, the cranial circumference was 
15 inches, and the weight of the fresh brain was 12 J ounces. The 
cranial circumference at eight years was 14J inches, and at twelve 
years 14J inches. Dr. Shuttleworth describes him as manifesting 
good powers of observation, but only able to express himself in 
a few monosyllabic words. He had considerable will-power, and 
though it was found impossible to train him to much that was 
useful, he was in no sense a low-grade idiot. A very complete 
examination of this case was made and recorded by Professor 
J. D. Cunningham and Dr. T. Telford-Smith (1895).* 

Joe, who was examined by Dr. Ireland in the Lancaster 
Workhouse at the age of forty-five years, had a cranial circum- 
ference of 17 inches, and attained the unusual height of 
5 feet 9 inches (in boots). Until eighteen months previously 
he had earned enough wages to keep himself, and he died at the 
age of sixty years, of phthisis. This case also was fully described 
by Cunningham and Telford-Smith. 



MONGOLIAN AMENTIA. 

The Mongolian or Kalmuc variety of amentia was first so named 
by Dr. J. Langdon Down, from the resemblance of these persons 
in certain particulars to members of the Mongolian race. Their 

* Transactions Royal Dublin Society, vol. v., Series 2, Part VIII. 
An excellent recent account of microcephaly is that by Dr. Giovanni 
Mingazzini {Monatsschrift filr Psychiat. und Neurologie, Band vii., Heft 6, 
June, 1900). This gives most of the literature to date. 



1 82 Mental Deficiency 

peculiar characteristics give rise to a physiognomy and clinical 
appearance which is exceedingly distinctive and unmistak- 
able, but it must be admitted that not a few aments are met 
with who present only some of the features of this class, and 
who are thus intermediate between the Mongolian and the simple 
variety of amentia. Such are often called " semi- Mongols." 

The number of Mongols is not large. If only those with well- 
marked characteristics be included, they probably do not form 
more than about 4 or 5 per cent, of all aments. One often hears 
it said that they are on the increase, but I know of no data in 
support of this statement, and impressions regarding such 
matters are notoriously misleading. Still, it is by no means 
improbable. Many of the physical features of this class are 
noticeable at, or shortly after, birth, and this fact, together with 
their retardation of development, causes them to be not infre- 
quently seen in the consulting-room and the out-patient depart- 
ment of hospitals devoted to children. They bear a superficial 
resemblance to, and are often confounded with, cretins ; in fact, 
this type of amentia used formerly to be called " cretinoid " 
idiocy. 

Causation. — Dr. G. A. Sutherland,* in one of the best accounts 
we have of Mongolism as seen in the early years of life, remarks 
that these children " resemble each other so closely that they 
appear to be members of the same family," and he very truly 
argues from this that the cause is more likely to be particular 
than general, such as those concerned in the production of 
the majority of aments. " General causes," he says, " such as 
parental alcoholism, nervous disease, or insanity in the family, 
etc., are not likely to produce such an exact type of disease as 
exists in Mongolism. It seems probable that one and the same 
cause is at work in all cases." Sutherland found that, out of his 
total of twenty-five cases, syphilis was definitely present in eleven 
patients, and from the symptoms and history it was strongly 
suspected in three others. He therefore suggests that, whilst 
further investigation is required to ascertain the exact etiological 
factor, the condition may turn out to be a parasyphilitic one. 

It is undoubtedly true that the curious assemblage of physical 

* G. A. Sutherland, " Mongolian Imbecility in Infants," based on a 
study of twenty-five cases, Practitioner, December, 1893. 



The Clinical Varieties of Primary Amentia 183 

signs which are present in typical Mongolism do suggest a certain 
uniformity of causation in these cases. But it is necessary to 
remember that Mongolism consists in a particular combination 
of anomalies rather than in anomalies which are distinctive in 
themselves, and there are many ordinary aments who possess 
one or more of the features which go to make up the tout ensemble 
of the Mongol ; in fact, I do not know of any single feature of 
these persons (with the possible exception of the tongue) which 
may not be seen in other aments. It is, therefore, the combina- 
tion only which is distinctive. Granting, however, that this 
is probably due to a uniform cause, it by no means follows 
that this is some single and particular etiological factor. With 
regard to the question of syphilis, the evidence produced by 
Dr. Sutherland is undoubtedly very strong ; but, as equally 
strong evidence to the contrary, it may be stated that, in over 
twenty cases of this variety in which I investigated the family 
history, I was unable to discover any preponderance of syphilis, 
an4 in some of the cases I have no hesitation in saying positively 
that syphilis was not to be thought of. In nearly all my cases 
there was a neuropathic family history, and frequently a strong 
tubercular taint ; but over and beyond this, what I did fre- 
quently find (and what I think may possibly be the factor 
common to this type) was a history pointing to a condition of 
uterine exhaustion or ill-health of the mother during gestation. 
Many of the patients were the later born of a large family, often 
numbering as many as ten or twelve, and where this was not the 
case there was usually a state of severe physical prostration of 
the mother during the gestation period.* It is possible that 
many conditions, syphilis included, may bring this about, and 
I have on several occasions seen children produced by weakly 

* Dr. Bodil Hjorth, of Copenhagen, in a paper recently published on the 
" Etiology of Mongolism," gives particulars regarding the antecedents of 
twenty-one cases. " The observed conditions assumed as possible cause s 
are phthisis in the parents or grandparents, neuropathic heredity, and 
alcoholism. None of these occur so often as to show a preponderating 
influence. There is no record of syphilis in any of the cases. Twins 
presenting the specific characters are noted, these children being the 
eighth and ninth of a family of ten. Out of the twenty-one cases, twelve 
were the last children in the family" (Journal of Mental Science, January, 
1907). 



184 Mental Deficiency 

mothers, at the end of the child-bearing period, who had quite a 
Mongolian type of physiognomy, but who were mentally normal. 

I am disposed to think, therefore, that Mongolian amentia is the 
result of the two factors, morbid heredity and uterine exhaustion, 
and that with a pronounced degree of the latter the hereditary 
defects may be only slight. In one of my cases there was no 
neuropathic heredity, but the mother had suffered from severe 
albuminuria and anaemia whilst carrying the child. 

Pathology. — The brain of the Mongol is usually smaller and 
less complexly convoluted than that of the normal person. In 
addition, there is a diminution in the size of the pons, medulla, 
and cerebellum. This is not a noticeable peculiarity of ordinary 
aments, and it seems to be a constant characteristic of this class. 
Dr. A. W. Wilmarth,* as a result of the examination of five 
Mongols, found that the brains were of good size for imbecile 
brains, but that the pons and medulla were very small, being 
only about half the normal weight. He suggests that the low 
nutrition of these patients (and possibly other anatomical pecu- 
liarities) may be due to the imperfect development or absence 
of certain cell groups in this region. 

I have had the opportunity of examining the central nervous 
system of a male Mongolian who died aged fourteen days. In 
this the weight of the complete encephalon was 340 grammes, 
which may be considered as normal. The weight of pons, 
medulla, and cerebellum was 19 grammes, the relationship 
between these structures and the cerebrum being thus 1 to 16*8. 
According to Huschke, the normal relationship between these 
and the cerebrum is as 7 to 93 (roughly, one-thirteenth) at birth. 
The relative and absolute weight of the cerebellum undergoes a 
considerable increase with age, however, and in the adult the 
proportion to the cerebrum is as 13 to 8y (roughly, one-seventh). 
It is thus seen that in this case there is a definite diminution 
of these basal structures. No other naked-eye changes were 
observed. Microscopical examination showed an immature con- 
dition/of the cells and tracts of all portions of the encephalon 
and spinal cord ; but the degree of development did not appear 

* A. W. Wilmarth, " Report on the Examination of One Hundred 
Brains of Feeble-Minded Children," Alienist and Neurologist, October, 
1890. 



Plate XII. 





To face page 184.] 



The Clinical Varieties of Primary Amentia 185 

to be behind that of a normal nervous system of similar 
age. The brain cells of the normal child at birth are in a very 
embryonic condition, however, and it is hardly to be expected 
that any microscopical differences would be discoverable at this 
early age. 

It is very probable that the imperfect development of the 
basal parts of the encephalon results in a deficient expansion of 
the base of the skull, and Sutherland plausibly suggests that this 
may be a factor in causing the characteristic physiognomy of 
these persons. 

It may be stated that, beyond the presence of congenital 
malformations common to all aments, dissections have hitherto 
failed to reveal any abnormality of glandular or other bodily 
structures which would account for the peculiar characteristics 
of this class. The amentia is in all probability idiopathic 
and due to hereditary defects, but these special physical 
characteristics may be brought about by morbid influences 
or malnutrition acting during the period of intra-uterine 
growth. 

Description. — Physical Condition. — The three anomalies most 
constantly present in Mongolism, and whose combination may be 
said to be characteristic of this condition, are of the skull, the pal- 
pebral fissures, and the tongue. These are often so pronounced 
as to render a diagnosis possible at, or very shortly after, birth. 
In exceptional cases, however, only two may exist. In addition, 
there are many other peculiarities of frequent occurrence ; but 
these are less distinctive of Mongols, many of them being by 
no means rare in ordinary aments. Several illustrations of 
this type of amentia are shown in Plates XII., XIII., 
and XIV. 

The skull is small, rounded, and diminished in its antero- 
posterior measurement (brachycephalic), the face and occiput 
being considerably flattened. But there is no marked recession 
of the frontal and supra-occipital regions, so that, although 
Mongols are of the small-headed type of aments, the cranial con- 
formation is markedly different to the microcephales proper. The 
palpebral fissures are narrow and oblique, sloping downwards and 
inwards. It was this peculiarity which caused Langdon Down 
to apply the name " Mongol " to the type ; but although generally 



1 86 Mental Deficiency 

present, it is not invariably so. Dr. C. H. Fennell,* in a series 
of twenty-one cases, found it absent in three, whilst in one the 
direction was reversed. Moreover, it occurs in the mentally 
sound, and I know several remarkably intelligent persons pos- 
sessing this peculiarity. 

An exceedingly characteristic feature is the tongue, which 
is unusually large, marked by hypertrophied circumvallate 
papillae, and scored by a series of irregular transverse fissures. 
Fennell regards this condition as pathognomonic, and says : 
" In the examination of the tongue in over 200 idiots of all 
other types, I met with none which at all recalled it." But 
a few Mongols of mature age do not present this peculiarity. 
Some very interesting details with regard to the tongue have 
been recorded by Dr. John Thomson,! of Edinburgh. He finds 
that, although the organ may be noticeably large at birth, the 
other characteristics of fissuring, swollen papillae and sodden 
rawness, do not develop until considerably later. He says the 
enlargement of the papillae most commonly begins between the 
third and ninth months, whilst the fissuring generally begins to 
appear in the course of the third or fourth year. It may be 
present in a slight form, however, during the second, and it may 
not be noticeable till as late as the sixth year. Dr. Thomson 
suggests that these changes may be partly due to an abnormal 
vulnerability of the mucous membrane, but that what chiefly 
determines the swelling and cracking is the habit of sucking the 
tongue which is commonly present in these children. I am of 
opinion that this is an exceedingly probable explanation, for it is 
an undoubted fact that a very marked feature of Mongolism is the 
tendency to chronic inflammatory conditions of skin and mucous 
membranes ; whilst Thomson has shown that the exciting factor — 
tongue-sucking — occurs in at least 80 per cent, of these patients. 

The ears are usually small and rounded, the nose short and 
squat, with triangular nostrils which often look forwards rather 
than downwards. Epicanthus is often seen, and strabismus and 
nystagmus are frequent in the first few months of life, but tend to 

* C. H. Fennell, " Mongolian Imbecility," Journal of Mental Science, 
January, 1904. An excellent account of Mongolism as seen in institutions, 
based upon twenty-one cases. 

j- John Thomson, " Notes on the Peculiarities of the Tongue in Mon- 
golism," British Medical Journal, May 4, 1907. 



Plate XIII. 




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To face page 186. 



The Clinical Varieties of Primary Amentia 187 

disappear as .the child grows. Speckled irides are very common, 
a condition to which my attention was first drawn by Dr. R. 
Langdon Down. The same observer also considers that hyper- 
metropic astigmatism is unusually prevalent. The hair is generally 
very scanty and wiry. There is frequently seen a bright red 
flush upon the scheek of these patients, very much like that 
occurring in myxcedema. The palate is often high and narrow, 
the mouth open, and the tongue partly protruding. Adenoids 
are exceedingly frequent. 

The hands and feet are commonly broad, flabby, and ex- 
ceedingly clumsy-looking ; in fact, they may often be said to be 
spade-like. Dr. Telford- Smith described a curious incurving of 
the little fingers as very characteristic of Mongolism, but in my 
experience it is no more common in this type than in aments in 
general. What I have frequently found is that both the little 
fingers and thumbs are much shorter than normal, and that whereas 
in the ordinary person or ordinary ament the tip of the little 
finger usually ends opposite the last joint of the ring-finger, in 
Mongols it is very common to find it extend no farther than the 
middle of the second phalanx. In the early years of life there 
is usually an exceedingly lax condition of the joint ligaments, 
and this gives rise to a greatly increased mobility. Very often 
the fingers and knees can be hyperextended to a considerable 
degree. Knock-knee and flat-foot are common. The skin is 
rough and dry, and often covered with fine hairs. The sub- 
cutaneous tissues frequently have a curious boggy feeling, like 
that present in myxcedema, but there is no pitting on pressure. 
The abdomen is usually large and tumid, particularly in infancy, 
and umbilical hernia is occasionally seen. 

In many of these persons the circulation is very defective, and 
blueness and coldness of the extremities, sores and chilblains, 
are exceedingly prevalent. This is probably due to congenital 
cardiac anomalies, such as imperfect closure of the foramen ovale, 
pulmonary stenosis, etc. ; but in some instances it may be 
the result of intra-uterine endocarditis. Dr. A. E. Garrod* 
described five cases of Mongolism in which congenital cardiac 
lesions were found, and one-fifth of the cases examined by 
Dr. Sutherland presented well-marked systolic basal murmurs 

* Archibald E. Garrod, British Medical Journal, October 22, 1898. 



sN Mental Deficiency 

which were evidently congenital. One very marked peculiarity 
of these persons is their tendency to chronic inflammatory 
lesions of the respiratory and alimentary tracts. Nasal catarrh, 
bronchitis, and diarrhoea are exceedingly common, and the 
majority are constant sufferers from blepharitis, rhinitis, and 
cracked lips. 

Such are the chief physical peculiarities of this interesting 
variety of amentia. It is rarely that they are all present in any 
one person, and there is probably no one of them which is really 
pathognomonic of this condition, except perhaps the tongue. 
This latter, with the peculiar conformation of the skull and 
palpebral fissures, the cheek flush, and the general tendency to 
mucous catarrh, seem to me to constitute the essential symptom- 
complex. As a rule, these peculiarities persist throughout life ; 
but I have seen a few cases in which advance of time seemed to 
bring about a marked amelioration, and caused them to become 
much less evident. This, I think, is more common in the 
originally milder cases ; but a short time ago Dr. Caldecott, of 
Earlswood Asylum, showed me an imbecile whom the casual 
observer would hardly have recognized as a Mongol, but who in 
former years had possessed very well-marked characteristics. 

As a rule, Mongols die early, the chief cause of death being 
phthisis. They are rarely met with above the age of thirty years, 
although at the present time there are two at Normansfleld 
between thirty and forty ; and Dr. R. Langdon Down tells me 
that he had a female Mongolian under his care for many years 
who reached the advanced age of fifty-seven years. 

Mental and Nervous Condition. — The mental characteristics of 
this class are not nearly so distinctive as are the physical ; never- 
theless, there are several peculiarities common to them. From 
the beginning, the Mongolian infant is placid, good-tempered, 
and readily amused. There is at first no apparent mental hebe- 
tude ; on the contrary, he often looks bright and intelligent, has 
plenty of curiosity, is attracted by everything around him, and 
is very imitative. But one of the most common of the early 
signs of amentia is seen in the tardy evolution of the power of 
sitting up, walking, and talking. Moreover, he is full of grimaces 
and facial contortions, which are accompanied by wrinkling of 
the skin, and are foreign to the normal child. As he grows up 



Plate XIV. 
PRIMARY AMENTIA (MONGOLIAN VARIETY). 




Fig. 37. — A female Mongolian. Age, 3 months. 
{From a photograph lent by Dr. J. Thomson.) 




Fig. 3S. — A male Mongolian. Age, 14 months. With 
talipes varus and "cubitus varus. Died 2 months 
later of general tuberculosis. 

{From a photograph lent by Dr. J. Thomson) 



To face page iE 



The Clinical Varieties of Primary Amentia 189 

the want of intellect becomes more and more apparent. But he 
still retains his happy disposition ; he is very affectionate, readily 
pleased, and usually a great favourite with all around him. He 
often has a very considerable power of mimicry, as well as a 
remarkable sense of rhythm and love of music, and many of these 
children are adepts at drill and dancing. 

The degree of intellectual deficiency varies very considerably, 
and on the whole I am inclined to think that there is a direct 
relation between this and the intensity of the bodily signs. 
Many of them are merely feeble-minded, a few are pronounced 
idiots, but the majority belong to the medium grade of defect. 
The milder members generally learn to read, write, and perform 
simple duties with a fair amount of intelligence, but their power 
of summing is decidedly poor. Dr. Shuttleworth says that some 
of these, after appropriate education, even pass muster with their 
brothers and sisters. The imbeciles, on the other hand, rarely 
make much headway, and, although very imitative, it is not often 
that in them this faculty can be turned to any practical purpose. 
In the performance of useful work they are often surpassed by 
ordinary imbeciles of far more vacant and less prepossessing 
appearance. Even in the milder cases the clumsy and ill-formed 
condition of the hands usually precludes any kind of work 
requiring dexterity, and most of these persons do best in the 
garden or on the farm. 

Cerebral complications are not common in this class, and actual 
paralysis and epilepsy are rare in comparison with other aments. 

It will be seen that Mongolian aments have certain points in 
common with sporadic cretins, and in the early stages a con- 
siderable number are treated with thyroid gland, and hopes of 
amelioration held out to the parents, as a result of a mistaken 
diagnosis. The chief points of resemblance are the general back- 
wardness of bodily development, the stumpy and spade-like hands 
and feet, the squat nose, and the bogginess of the subcutaneous 
tissues. Careful examination, however, will reveal far more 
points of difference. In the Mongols the head is small and 
rounded, instead of large ; the tongue, although somewhat like 
that of the cretin in being large and protruding, is marked by 
hypertrophied papillae, and later by numerous fissures. The 
slant of the eyes, the lax joints, and the chronic catarrh of the 



190 Mental Deficiency 

Mongol are very distinctive ; whilst his active, bright, and 
vivacious manner is totally unlike the dull, expressionless inertia 
of the cretin. Finally, the rate of bodily growth is entirely 
different in the two conditions. I have known thyroid gland, 
also thymus and pituitary extracts, given to Mongols persistently 
for years, but never with any appreciable amelioration of the 
physical or mental defects ; whereas, as is well known, the effect 
of thyroid upon the cretin is remarkable. 



THE COMPLICATIONS OF PRIMARY AMENTIA. 

We have described three types — namely, Simple, Microcephalic, 
and Mongolian — as the chief clinical varieties of primary amentia. 
Any of these three, however, may be complicated by certain 
severe developmental anomalies or special pathological condi- 
tions which produce more or less distinctive clinical features, and 
these we shall now allude to. They are, in order of frequency : 

Epilepsy. 
Paralysis. 
Hydrocephalus. 
Porencephalies. 
Sclerosis. 
^Deaf-mutism. 

It is to be remarked that, in the cases we are now considering, 
these conditions merely accompany and complicate a mental 
deficiency which is primary ; nevertheless similar lesions may, 
in a small number of instances, actually produce amentia. Such 
cases will be dealt with in a subsequent chapter. 

Epileptic and Other Convulsions. — Convulsions in some form or 
other, but chiefly epileptic, are the most common complication 
of primary amentia. A special examination with regard to this 
condition in over 500 patients showed that in cases presenting 
no paralysis or other indication of gross cerebral lesions, and in 
whom therefore the attacks were idiopathic epilepsy, convulsions 
occurred in 37 per cent. ; whilst in patients presenting signs of 
gross lesions they occurred in 70 per cent. In the great majority 
of the latter, however, the fits were indistinguishable from 
ordinary epilepsy. 



The Clinical Varieties of Primary Amentia 191 

With regard to the degree of amentia, it was found that con- 
vulsions occurred in 11 per cent, of the feeble-minded, 42 per 
cent, of imbeciles, and 56 per cent, of idiots. It is possible, 
however, that these figures may be somewhat too high for 
primary aments in general, since they largely relate to institu- 
tion patients, and may therefore contain an undue proportion of 
the worst cases. Convulsions are most frequent in the simple 
and microcephalic varieties, and are relatively rare in the Mon- 
golians. 

With regard to the convulsions, as far as could be ascertained 
they were in the great majority of cases typically epileptic, and 
several of the merely feeble-minded patients have definitely 
affirmed the existence of a premonition or aura. In the more 
severe grades of defect the mental condition usually precludes 
any inquiry upon this point, but trained attendants can often 
foretell the onset of a fit by the appearance of the patient. Most 
of the attacks are of the major variety, although in a few cases 
minor seizures occur also. Their severity varies greatly, some 
being of the mildest possible type, others exceedingly severe and 
protracted. Their frequency is also subject to great variation. 
In some patients the first convulsion appears in the early months 
of life, and they thence continue almost daily during the exist- 
ence of the patient. In other instances, after frequent fits 
during many weeks or months of early childhood, the patient 
remains free for years, he then has a few more, and these are again 
followed by years of quiescence. In yet other cases, after an 
initial series of fits, there is no recurrence. I have known several 
persons who have only experienced two or three seizures in the 
course of twenty years or more. It is hardly safe to reckon on 
the absence of epilepsy in any particular sufferer from primary 
amentia, although as a rule the fits make their first appearance 
not later than the second decade. 

The effect of the convulsions is much the same as in the 
ordinary individual, and appears on the whole to depend upon 
the frequency and severity of the attacks. If severe and often 
recurring, the patient rapidly loses even his limited acquirements ; 
whilst if slight and seldom, the effect may be infinitesimal. 

In addition to epilepsy, the following other conditions may be 
mentioned as being occasionally seen in primary aments : Chorea 



19 2 Mental Deficiency 

is not very common, but is found in some instances. Various 
forms of athetosis are fairly frequent in the severer grades. In- 
tention tremor is occasionally seen ; whilst I saw at Darenth a few 
years ago two imbeciles (brother and sister) affected with a 
constant rhythmic tremor of the whole body, closely resembling 
paralysis agitans. The tremor was so great that articulate speech 
was impossible ; the fingers could not pick anything up, nor could 
they retain their hold of any object. In each instance the tendon 
reflexes were greatly exaggerated, and ankle and patellar clonus 
were well marked, but Babinsky's sign was absent. 

Paralysis. — The next most common complication is paralysis. 
This, like epilepsy, is least frequent in the milder, and most so in 
the severer, grades of amentia, and, generally speaking, the extent 
of the paralysis is directly proportionate to the amount of mental 
deficiency. In a small number of cases, particularly amongst the 
microcephalics, the condition is rather one of paresis and general 
muscular hypotonus and helplessness than of actual paralysis, 
and in such it is probably due to imperfect development of the 
efferent pathway. In other instances, it is due to the presence of 
a gross cerebral lesion, such as localized atrophy, porencephaly, or 
hydrocephaly. In these latter the paralysis is localized, and 
varies from a slight monoplegia to a severe hemi- or paraplegia. 
The affected limbs are small and ill-nourished, and often firmly 
contracted, and many of the worst cases are permanently chair - 
or bed -ridden. In a considerable number of these cases epileptic 
convulsions also occur. 

^Hydrocephalus. — Probably most cases of amentia in which 
hydrocephalus is at all pronounced are of the secondary form, and 
this condition, as well as porencephalus and sclerosis, will be more 
fully described in a subsequent chapter. But a few undoubted 
primary aments develop hydrocephalus with its characteristic 
symptoms, and the condition is not infrequently found post- 
mortem where it had not been suspected during life. 

Porencephalus. — True or false porencephaly is sometimes found 
post-mortem when there has been little indication of its existence 
during life. It cannot be diagnosed with certainty, but its 
presence may be suspected in cases of congenital hemiplegia which 
are accompanied by considerable non-development of the affected 
limbs and marked flattening of the opposite half of the skull. 



The Clinical Varieties of Primary Amentia 193 

Sclerosis. — The usual indications of this complication are 
frequently repeated convulsions, followed by muscular tremor, 
weakness, or actual paralysis with contractures. In some cases 
there is persistent headache, the patient becomes more and more 
torpid, and dies after a succession of severe fits. 

Deaf-mutism is seen in a small proportion of primary aments. 
It calls for no remark beyond the fact that such a complication 
naturally imposes an insuperable barrier to successful training. 
On the other hand, the mild mental defect which results from 
this condition is greatly ameliorated, and in many cases removed, 
by appropriate education. 



13 



CHAPTER XIII 

SECONDARY AMENTIA AND ITS CLINICAL VARIETIES 

Hitherto we have been concerned with the primary form of 
amentia, in which the condition is due to an inherent incapacity 
for normal development on the part of the embryonic neuroblasts 
of the brain, the result of morbid heredity. 

There is, however, a much smaller group (probably comprising 
not more than about 10 per cent, of all aments) in which no such 
intrinsic defect exists, and in which the mental deficiency is 
brought about by some purely extraneous factor. This form of 
amentia is termed secondary, and will now be considered. 

Perhaps a connecting link between the primary and secondary 
forms is afforded by that variety of amentia which is due to 
epilepsy. In many such cases morbid heredity is present, and 
there may even exist some of the stigmata of degeneracy which 
are so characteristic of the primary form. But inasmuch as 
in these cases the amentia is clearly the result of the epilepsy, 
I have considered it better to look upon the mental defect as 
secondary, and we shall describe it in this place. 

With this exception there is a marked difference in the clinical 
aspects of the primary and secondary forms. The inherent 
blight of the former gives rise to numerous and widespread 
anomalies of anatomical development which are absent in the 
latter. As a consequence, the sufferer from secondary amentia is 
often readily distinguished from the primary ament by being well 
developed and well grown, and by his comely and prepossessing 
appearance. Occasionally, however, there are deformities and 
abnormalities peculiar to the variety, and dependent upon the 
particular pathological lesion present. Further, whilst in uncom- 
plicated cases of the primary group the general tendency is for 

194 



Secondary Amentia and its Clinical Varieties 195 

some degree of amelioration to take place as a result of suitable 
training, many of those of the class we are now considering are 
the result of cerebral lesions which are progressive, and the ten- 
dency is rather towards degeneration and ultimate dementia. 

In describing the clinical varieties of primary amentia, the 
classification adopted was based upon the presence of physiog- 
nomical characteristics. It is more convenient to describe cases of 
secondary amentia according to their particular pathogenesis. 

From this standpoint cases of secondary amentia may con- 
veniently be divided into two main classes. In the first of these 
the mental deficiency is brought about by a general or localized 
disease of the brain cells ; in the second it is due to some external 
factor influencing their nutrition. Each of these classes contains 
several clinical varieties. This chapter will therefore be divided 
into two sections, as follows : 

Section I. 
Amentia due to Cerebral Disease. 

Varieties : (i) Epileptic and eclampsic amentia. 

(2) Vascular, toxic, and inflammatory amentia, 

including certain special types, viz. : 

(a) Porencephalic. 

(b) Sclerotic. 

(c) Hydrocephalic. 

(3) Syphilitic anrentia. 

(4) Infantile cerebral degeneration. 

Section II. 
Amentia due to Defective Cerebral Nutrition. 

Varieties : (i) Cretinism. 

(2) Amentia due to nutritional defect. 

(3) Amentia due to sense deprivation. 

It may be well again to emphasize the fact that, although many 
of the etiological and pathological conditions present in secondary 
amentia may, and frequently do, complicate the primary form, we 
are only here concerned with such cases of amentia as are directly 
and entirely attributable to them. 



13- 



196 Mental Deficiency 

Section I. 

AMENTIA DUE TO CEREBRAL DISEASE. 

In this class the morbid anatomy consists of a (usually) localized 
arrest of neuronic development, which in most instances is accom- 
panied by lesions obvious to the naked eye. In a considerable 
number of cases degenerative changes supervene, in consequence 
of which dementia becomes added to the mental deficiency. 

EPILEPTIC AND ECLAMPSIC AMENTIA. 

It used to be the custom, in describing the varieties of amentia, 
to group together into one class all those persons who were, or 
had been, subject to epileptic or similar convulsions, and to label 
them " epileptic " or " eclampsic " aments. A close examination 
of this class, however, shows that it is really a most heterogeneous 
collection. 

It is, perhaps, not unnatural that the parents should see in 
these convulsions the reason and cause of the mental deficiency 
of their child, and, as a matter of fact, there is no other single 
etiological factor which is so frequently advanced as the " cause." 
To the lay mind " fits " are both impressive and alarming. It is 
not surprising that even medical practitioners should frequently 
be satisfied with this explanation, for they are fully aware of the 
mental hebetude and degeneration which may supervene upon 
epilepsy. But I am convinced, from the examination of some 
hundreds of aments suffering from epilepsy, as well as from careful 
inquiries into their family and previous personal history, that in 
the great majority no such causal relationship exists as is implied 
by the term " epileptic." 

The relationship existing between epilepsy* and amentia is of 
three kinds, as follows : 

1. Primary Amentia in which Epilepsy occurs as a Mere Com- 
plication. — This has already been considered in the chapter dealing 
with the complications of primary amentia (p. 190). 

* For convenience, the term " epilepsy " is here used to include epilepti- 
form as well as epileptic (idiopathic) convulsions. 



Secondary Amentia and its Clinical Varieties 197 

2. Idiopathic Epilepsy or Eclampsia causing Amentia. — It is 
with this group that the present account deals. 

3. Gross Cerebral Lesions causing Epilepsy and Amentia. — Here 
both the epilepsy and amentia are symptomatic of conditions 
which will be described in subsequent pages. 

The following table shows the chief points of difference between 
these three groups in which amentia and epilepsy co -exist : 

TABLE XV. 

Showing the Relation of Epilepsy to Amentia. 



Morbid heredity 

Condition of 
patient before 
the fits 



Nature of fits 



Condition of 
patient after 
fits have made 
their appear- 
ance 



Stigmata of de- 
generacy 

Prospects of im- 
prove ment 
under special 
training 



Group i. 
Primary amentia com- 
plicated by epilepsy. 



Pronounced 

Some degree of 
amentia or general 
backwardness usu- 
ally noticed 

Epileptic. Usually 
milder and less fre- 
quent than Group 2 

Degree of amentia 
often much greater 
than would be ac- 
counted for by the 
severity and fre- 
quency of fits 

Paralysis may be pre- 
sent also if a gross 
lesion co-exists 

Marked (except in 
highest grades) 

Dependent upon se- 
verity anct fre- 
quency of fits, but 
on the whole better 
than in Groups 2 
and 3 



Group 2. 

Secondary amentia. 

due to idiopathic 

epilepsy. 



Less pronounced 
Normal 



Epileptic, 
vere and 
quent 



Se- 
fre- 



Amentia usually 
mild, but much 
dementia 



No paralysis 



Slight 



Practically none 



Group 3. 

Secondary amentia and 

epilepsy due to gross 

cerebral disease. 



Absent 

Normal. Onset of fits 
can generally be traced 
to some definite morbid 
process affecting brain 

Epileptic. Occasionally 
epileptiform ; rarely con- 
stant, rhythmic tremor 

Considerable amentia 
may be present with 
mild and infrequent fits 



Paralysis often present 



Absent 



Dependent upon time of 
occurrence, site, extent, 
and nature of lesion, 
and upon severity and 
frequency of fits. Usu- 
ally intermediate be- 
tween Groups 1 and 2 



Epileptic Amentia. — It is common knowledge that frequently 
repeated severe convulsions, or even minor attacks, occurring in a 
person of mature cerebral development may give rise to dementia. 
The anatomical basis of this condition is a degeneration of the 
same cortical cells and fibres as are imperfectly developed in 



198 Mental Deficiency 

amentia.* If the development of these neurones is as yet incom- 
plete, as in the infant, it may be irremediably arrested, and a 
condition of secondary mental deficiency result. For the pro- 
duction of amentia, then, in addition to the factors which produce 
dementia, the convulsions must occur during the first few years of 
life. This is the case in a considerable proportion of epileptics, 
and Sir William Gowersf states that in 12*5 per cent, of cases the 
convulsions make their first appearance before the age of three 
years. In such cases the mental development of the patient may 
become arrested, so that whilst his body develops his mind is no 
more advanced than that of an idiot, imbecile, or feeble-minded 
person. Savage makes the statement that epilepsy " occurring 
before seven years of age is certain to leave the patient weak- 
minded "; but I am inclined to think that, if by weak-mindedness 
is meant amentia, this is a little too sweeping. Nevertheless, some 
degree of amentia does certainly result in many cases of epilepsy 
beginning thus early. On the other hand, the proportion of aments 
who owe their condition to this cause, and who are truly sufferers 
from epileptic amentia, is a small one. In my own series of cases 
I find that 3*5 per cent, only of aments belong to this variety, but 
this number must be regarded as merely an approximate estimate. 
The pathology of these cases has already been described ; it is 
usually that of arrested neuronic development plus degeneration. 

Epileptic aments differ considerably in their clinical features. 
In some the bodily condition is sufficiently unlike to be readily 
distinguishable from ordinary primary aments ; but there are 
others who so closely resemble that class that a diagnosis can only 
be made by most careful attention to the history and the capacity 
of the patient prior to the onset of the fits. It may be stated that, 
as a general rule, epileptic aments are better grown and developed, 
and possess fewer of the stigmata which are such a conspicuous 
feature of the primary group. 

The degree of mental deficiency varies from a mild amount of 
feeble-mindedness to a state resembling idiocy ; but this latter 
condition is more often the result of a superadded dementia than 
of a pure mental arrest. In the milder cases, although the patients 

* This has been recently shown in J. S. Bolton's exhaustive work, 
" Amentia and Dementia," Journal of Mental Science, 1905 et seq. 

f Sir W. R. Gowers* article " Epilepsy," in Clifford Allbutt's " System 
of Medicine," vol.]vii. 



Secondary Amentia and its Clinical Varieties 199 

rarely make much headway with school learning, a certain amount 
of manual training is possible, and many of them are able to do 
more or less useful work. But the persistence of the fits gradu- 
ally strips these persons of any acquirements they may have pos- 
sessed, and in the majority of cases dementia is but a question of 
time. On the whole, it may be said that the prospects of ameliora- 
tion by training and the general prognosis of this class are of the 
most unfavourable description. There are a few cases of epileptic 
amentia in which the fits cease, and in these the mental condition 
may improve very considerably. There are other cases in which 
a diminution of the fits and some degree of mental improvement 
takes place, apparently in consequence of medicinal treatment and 
regimen ; but these cases are decidedly exceptional, and in no 
instance is real mental deficiency, once produced, ever overcome. 

There is one mental feature which is common to most of these 
cases, and that is, a general irritability and intractability. Epi- 
leptic aments are often exceedingly stubborn and difficult to 
manage ; they are prone to sudden outbursts of temper and 
violence, and they are, in fact, probably the most untrustworthy 
of all the varieties of mental deficiency. 

With regard to the fits themselves there is little to be said. They 
may be of either the minor or major variety, or of both. They 
are occasionally preceded by a definite aura, or by some recog- 
nizable alteration in the appearance of the patient, and they are 
usually followed by a varying period of intellectual, sensory, and, 
at times, motor exhaustion, transient paresis being by no means 
uncommon. In a certain number of cases they seem to be 
directly excited by indigestion, constipation, undue excitement, or 
some determinate cause ; in others they occur independently of 
any ascertainable factor. The frequency of some is diminished 
by dieting, careful regulation of the daily life, and the administra- 
tion of drugs, of which the most valuable are still the bromides. 
In many cases, however, the fits persist in spite of all treatment, 
and hopeless dementia results. 

Illustrative Cases. 
L. /., male, the fourth born of a family of eight, of whom 
three only are now alive ; the remaining five died in infancy, and 
all of them were subject to convulsions. The patient's father 



200 Mental Deficiency 

was strongly addicted to alcohol, and died at the age of forty- 
seven, cause unknown ; his father's father died aged fifty-seven, 
and was paralyzed for six years before death. The patient's 
mother is alive and in tolerably good health ; she had thirteen 
brothers and sisters, all of whom are dead, several of consumption, 
and her father died aged fifty, of asthma. 

The patient had fits when a month old, and they have con- 
tinued on and off ever since. During infancy he used to have as 
many as ten daily. With the exception of the fits, he was not 
noticed to be different to other children until schooling began. 
He was then found unable to make any progress, and after a 
short time was discharged. He remained at home pottering 
about, but doing no regular work, until seventeen years of age, 
when he became so unmanageable that he had to be sent to an 
asylum. On admission he was a pale-faced, somewhat undersized 
youth, with slight stigmata of degeneracy. He was dull of com- 
prehension, and slow in realizing what was said to him. Memory 
very defective, and in replying to questions he would constantly 
repeat himself. Able to draw a little, but unable to read, write, 
or sum, and decidedly feeble-minded. He was liable to attacks 
of violence before the fits, and would then attack anyone who 
might be near him. After the fits he remained heavy and 
stuporose for a day or more. He admitted that he was excited 
before the fits, and said it came over him " all of a sudden." He 
complained a good deal of headache. He remained in practically 
the same condition, having fits at the rate of three or four weekly, 
and being either too excitable or too stuporose to do any work. 
He is now, at the age of twenty, showing signs of dementia. (See 
Plate XV., Fig. 39.) 

F. S., female, the eighth of a family of thirteen, three of whom 
are dead, the remainder living, and said to be in good health. 
The father has been insane in an asylum. The patient had 
severe fits whilst cutting her teeth, and they recurred almost 
daily until she was five years old. Since then they have only 
returned at rare intervals. She always seemed idiotic, had no 
idea of playing like the other children, and received no education 
of any kind. She remained at home until in her teens, but was a 
great trouble, being unable to speak or look after herself in any 
way. She would wander aimlessly about the house, and was 



Plate XV. 



- 










^^^^^ 


>A 


' 


mi 1 4 


' 


' 









To face page 200.] 



Secondary Amentia and its Clinical Varieties 201 

generally very restless ; if left alone would be sure to get into 
trouble, and was occasionally violent and aggressive. She 
finally became so unmanageable that she had to be sent to an 
asylum. 

On admission she was found to be a pronounced idiot. She 
had no understanding of what was said to her, and was unable 
to articulate. She spent the day sitting in a chair rocking herself 
to and fro, and occasionally screaming or making a grunting 
noise. She had no idea of personal cleanliness, and had to be fed 
with a spoon. She destroyed everything she could lay her hands 
on. At the present time she is twenty-seven years of age, and 
her condition is practically unchanged. She has had a few 
epileptic fits at rare intervals, the longest period of intermission 
being four years. 

To these two examples many others might be added, but they 
are sufficient to illustrate the unfavourable type of amentia 
which may result from severe epilepsy in early life. The effect, 
as already remarked, is not always so serious, and I know 
several instances in which but a mild degree of mental deficiency 
has been produced, and where more or less continuous occupa- 
tion is possible. But I think these latter cases are exceptional. 
There is no doubt that the prospect of improvement is greatest 
where the convulsions can be relieved by treatment, and hence 
the importance of careful medical supervision of these cases. 
Into the question of treatment I do not propose to enter, since 
it is that of ordinary epilepsy. It may, however, be stated that 
attention to the diet and the ordering of the daily life are of the 
utmost importance, whilst of drugs the bromides, in combination 
with borax, will usually be found the most efficacious. 

Eclampsic Amentia. — Instability of the nerve cells of the brain 
is a normal characteristic of infancy, and is probably in no small 
measure due to the rapid growth which takes place during the early 
months of life. At the end of the first year the brain weighs three 
times as much as it did at birth. As a consequence there is no 
doubt that the child is much more predisposed to convulsions than 
is the adult ; but although convulsions are exceedingly common in 
infancy, I am of opinion that no ordinary excitant will produce 
them in a healthy child of good heredity. Where they occur, 
there is either some special inherited predisposition, or else the 



202 Mental Deficiency 

natural instability has been markedly exaggerated by a dis- 
turbance of cerebral nutrition caused by bodily ill-health. Where 
this special predisposition exists, such simple exciting factors as 
acute indigestion, constipation, dentition, or the ordinary febrile 
ailments of childhood, will suffice to determine convulsions. 
Where no predisposition is inherited, it may be acquired in con- 
sequence of anaemia, malnutrition, chronic disturbances of the 
alimentary tract, and, above all, rickets. 

It is thus seen that, theoretically, infantile convulsions fall into 
two groups — those which are the result of an inherited predis- 
position, and those in which the tendency is acquired. The 
former must be considered as undoubtedly identical with idio- 
pathic epilepsy, and they often persist throughout life ; he latter 
group are eclampsic only. But it is not uncommon for convul- 
sions which have been looked upon as simply eclampsic to recur, 
and to persist with all the features of true epilepsy ; consequently 
the division between these two conditions is one which is exceed- 
ingly difficult, and at times impossible, to draw.* 

The term " eclampsic amentia " should, of course, be limited to 
those cases of mental deficiency which are clearly the result of 
simple infantile convulsions due to this acquired predisposition. 
Such a result, in my opinion, seldom occurs, for in the great 
majority of children who thus suffer from a series of fits which do 
not recur, there is no permanent impairment of the mental 
faculties. In a few cases, however, some degree of amentia does 
result, but, as this is in all probability dependent upon a definite 
vascular or toxic lesion of the brain, it seems more desirable to 
include eclampsic cases under these headings. 

* It is of interest to note that Dr. R. O. Moon, as a result of his examina- 
tion of 200 cases of convulsions in children, says : " I have not been able 
to find any clear dividing-line between infantile convulsions or eclampsia 
on the one hand, and idiopathic epilepsy on the other. . . . On the con- 
trary, it has seemed to me that convulsions in early life may shade off 
indefinitely into epilepsy or epileptiform manifestations, so that it becomes 
often impossible to say where the one stops and the other begins." — 
" Some Observations on Convulsions in Children, and their Relation to 
Epilepsy" {Lancet, September 15, 1906). 



Secondary Amentia and its Clinical Varieties 203 



VASCULAR, TOXIC, AND INFLAMMATORY AMENTIA. 

It is by no means uncommon for symptoms indicative of a 
morbid state of the brain or its membranes to occur in childhood. 
Such cerebral symptoms may be due to injuries received during 
birth ; they may arise during, or subsequent to, one of the 
specific fevers ; they may follow a chronic inflammation of the 
nose or middle ear ; or they may occur entirely apart from any 
other illness. It is probable that a large number of the children 
in whom such symptoms are at all severe, die. Others, but rela- 
tively few, appear to make a complete recovery. In yet others 
death does not take place, but a permanent legacy remains in the 
shape of a gross cerebral lesion. 

The chief of these causes may be enumerated as asphyxia 
neonatorum and trauma (occurring before, during, or after birth) ; 
scarlet fever, measles, small-pox, enteric, whooping-cough, otitis, 
rhinitis, and possibly sunstroke ; lastly, primary inflammation 
of the cortical cells (polio -encephalitis of Striimpell), a disease 
analogous to the acute inflammation occurring in the anterior 
horns of the spinal cord. This last condition is probably a toxic 
one, and is the one of most importance. It is probably the under- 
lying condition of most cases of paralysis of cerebral origin 
occurring in infancy, as well as of many in which brain symptoms 
are attributed to sunstroke and other vague causes. 

The lesions which result from these varied causes are, broadly 
speaking, divisible into two classes — vascular and toxic. The 
former group embraces haemorrhage, thrombosis, and occasion- 
ally embolus, with, it may be, laceration of brain tissue. The 
latter group consists of cases in which there is a direct poisoning 
of the nerve cells. But in many instances both these conditions 
are present. 

In course of time secondary changes take place in and around 
the initial lesion, so that the final product is often very different 
to the change in the first instance. The chief ultimate results, 
as seen in post-mortem examinations made many years after- 
wards, are localized areas of softening, atrophy, and sclerosis ; 
cysts, meningo-encephalitis, pseudo-porencephaly or hemi- 
atrophy, and occasionally hydrocephaly. In these later stages it 
is usually impossible to say_whether the original lesion was 



c>4 Mental Deficiency 



vascular, toxic, or inflammatory, and as there are no characteristic 
clinical differences I see no object in treating of these as separate 
varieties ; they will therefore be considered together. 

But it is not to be assumed that the child who emerges from an 
illness of this kind with a gross lesion of the brain will necessarily 
be mentally defective. The efiect of the lesion upon the patient 
varies very much, and in the main three phenomena may result, 
either singly or in combination — namely, paralysis, epilepsy, and 
amentia. 

It is stated that if paralysis results from these lesions it is sure 
to be accompanied by some amount of mental deficiency. This 
is a complete mistake ; not only may amentia occur without 
paralysis, but marked paralysis may be present without amentia. 
I have seen quite a considerable number of cases in which there 
was paralysis of hand and forearm or foot and leg, or even of two 
limbs, without the slightest intellectual impairment ; indeed, in 
some of them the mental capacity was decidedly above the 
average. Dr. Sigmund Freud,* who has made a most careful 
study of the question, says : " Idiocy does not show any constant 
relationship to the other signs of infantile cerebral paralysis in 
respect of the degree of psychic arrest. There are cases of the 
severest paralysis with the intelligence scarcely affected, as, on 
the other hand, complete idiots without any signs of paralysis." 

With regard to epilepsy the case is somewhat different, and 
where the initial pathological process is such as to produce 
frequently repeated convulsions, there is a strong probability that 
some degree of amentia will result, and that dementia will ulti- 
mately supervene. But in these cases this result is by no means 
invariable, and it occasionally happens even in them for intel- 
lectual development to show no sign whatever of having been 
adversely affected. In exceptional cases it may even happen for 
the mind to show no trace of defect where both paralysis and 
epilepsy are present.! Finally, in a certain number of cases 

* Freud, " Infantile Cerebrallahmung," Wien, 1897. 

f A good example of this was described by the writer in an article on 
'* Amentia " in Mott's " Archives of Neurology," vol. ii. In this case there 
was right hemiplegia, with constant epileptic fits from birth, probably due 
to asphyxia neonatorum. The patient died, aged thirty-five years, fror 
exhaustion following a series of fits, and post-mortem examination revealed 



Secondary Amentia and its Clinical Varieties 205 

these infantile lesions give rise to amentia, and this may be 
accompanied by either paralysis or epilepsy, by both, or 
neither. It is thus seen that these infantile cerebral lesions are 
attended with widely different results, and although in this place, 
of course, we are only concerned with those in which amentia occurs, 
it will not be out of place to consider the reason for such diversity. 
Two possible factors influencing the result are the age of the 
patient when the lesion occurs and the inherited potentiality of 
the neuroblasts. In the new-born child cortical lamination is 
not yet complete, and there are a large number of neuroblasts 
lying among more fully developed nerve cells. I am inclined to 
think that a considerable number of these never attain mature 
development, for such immature cells may often be found in 
middle life. In this, as in other matters, Nature seems to act 
lavishly, and to provide a far greater number of cells than are 
developed by the stimulus of incoming sensations which comprise 
" education." In fact, there appears to be a potentiality of 
cerebral development which is never attained by the individual ; 
although it is probably to the gradual bringing into play of these 
neuroblasts that the progressive mental evolution of the race is 
due. With the lapse of years, doubtless, the developmental 
capacity of these embryonic cells becomes progressively less, and 
hence the older the child the more serious is likely to be the 
result of one of these lesions. Before cortical lamination is 
complete, however, I see no reason why their inherent poten- 
tiality should be inferior to others amid which they lie. Conse- 
quently it is not improbable that the destruction of nerve cells 
caused by a lesion occurring at or shortly after birth may be 

chronic meningo-encephalitis of the whole of the motor region of the left 
hemisphere. There was also considerable non-development of this hemi- 
sphere, its weight being 105 grammes less than the right, and there was 
chronic interstitial sclerosis, with diminished number of nerve fibres, 
throughout the corresponding upper efferent tract. The motor lesion had 
been compensated to a great extent by a numerical increase of Betz' cells 
of the opposite hemisphere. And yet this patient showed no trace of 
amentia, and, in spite of his paralysis and epilepsy, was able to earn his 
living until nearly twenty years of age. He was then admitted to the 
workhouse in consequence of the fits, and subsequently transferred to the 
asylum on account of post-epileptic insanity. At the time of his death 
there was practically no dementia. 



206 Mental Deficiency 

compensated by the development of these embryonic cells ; 
and where the two hemispheres have a function in common, 
it may even be possible for such compensation to take place in 
the opposite side to the one affected. This view, of course, is 
largely hypothetical, but it finds support in a number of clinical 
facts which are otherwise extremely puzzling. Thus, many cases 
have been recorded in which the greater part of one cerebral 
hemisphere was practically useless by reason of porencephaly or 
hemiatrophy, and yet the mental and motor defect was but 
slight ; indeed, in a large number of these cases the clinical signs 
(particularly of paralysis) are astonishingly insignificant when 
compared with the state of the encephalon.* Moreover, in the 
case already referred to, where practically all the large motor 
cells (of Betz) of the left leg area had been destroyed by a vascular 
lesion during birth, I was able to demonstrate a compensatory 
increase in the corresponding cells of the opposite hemisphere. 

A diminished neuronic potentiality, due to slight morbid 
heredity, is the explanation of those cases of so-calkd " develop- 
mental " amentia which apparently result from a compara- 
tively trifling cerebral lesion or general disturbance of health, 
and in all probability in the cases we are now considering the 
effect of these lesions upon the intellectual capacity of the 
patient is in no little measure influenced by his hereditary pre- 
disposition. One would also imagine that the ultimate amount 
of physical or psychic impairment in these cases would be con- 
siderably influenced by the amount of special training received 
by the patient during infancy. 

* On this subject see a very interesting article on " Secondary Degenera- 
tion following Cerebral Lesions," by W. G. Spiller [Journal of Nervous 
and Mental Disease, New York, January, 1898). Dr. Spiller describes the 
case of a boy in whom " the motor fibres of the left cerebral hemisphere 
were totally destroyed, and yet the boy was able to walk without a crutch, 
although in an imperfect manner ; he had no use of the right upper limb." 
Spiller says : " The conviction is forced upon one that the motor fibres 
to the right lower limb were transmitted through the pyramidal fibres 
from the right cerebral hemisphere. . . . The nervous system can adapt 
itself much better to altered circumstances if destruction of tissue occurs 
before the nerve-cells and fibres are fully formed, and it would seem 
that even additional fibres may develop." He quotes several similar 
cases which have been recorded by von Monakow, Mahaim, Dejerine, 
Thomas, and Zacher. 



Secondary Amentia and its Clinical Varieties 207 

With regard to the kind of lesion, Freud doubts whether it is a 
factor of much importance. He says : " One is as likely to see a 
brain with diffuse lobular sclerosis, with extensive blood-cysts, 
porencephaly, and the like, whether the individual was idiotic or 
relatively well developed mentally." I cannot but think, how- 
ever, that in many cases the secondary changes taking place in 
and around the diseased focus have contributed not a little to the 
patient's mental state. Some of the initial lesions tend to become 
localized and shut off, others to spread and cause diffuse changes, 
and it seems to me that such differences, probably by bringing 
about alterations of intracranial pressure, cannot be without 
effect upon the general brain function, and therefore the mental 
capacity. 

But undoubtedly the most important feature of these lesions is 
their situation and extent. If confined to the motor cortex or its 
downward prolongations, the result will probably be paralysis 
without amentia. In a considerable number of cases, however, 
lesions of the motor cortex also produce convulsions which may at 
first be Jacksonian, and ultimately become typically epileptic. 
It may even happen for a subcortical focus of disease to produce 
similar convulsions.* As a consequence amentia and dementia 
may be induced. A lesion in or near the motor cortex may excep- 
tionally cause epilepsy without paralysis, and here also the convul- 
sions may bring about subsequent mental deterioration ; in such 
cases paralysis may supervene later. A lesion elsewhere may give 
rise to epilepsy, either by acting as a source of reflex irritation, or 
by causing an increased intracranial pressure. Finally, a lesion 
of the more purely psychic areas (probably the frontal, prefrontal, 
and parietal lobules) may produce amentia without either 
paralysis or epilepsy. It is necessary to remember that not only 
may secondary pathological changes be induced by any of these 
lesions, but that an arrest of development may occur in far 
removed portions of the encephalon which are functionally 
correlated. The involvement of both hemispheres, as shown by 
a paraplegia, is of far more serious import than where one side 
only is affected. 

To sum up, we may say that a severe lesion of the psychic 

* Such a case was described by the author in Mott's " Archives of 
Neurology," vol. i. 



208 Mental Deficiency 

areas will probably produce amentia without paralysis, and a 
lesion of the motor areas paralysis without amentia. But either 
of these may give rise to epilepsy, and this may also result from 
a lesion elsewhere. As a result of this epilepsy, amentia, and sub- 
sequent dementia, may be induced. 

The clinical symptoms which usher in these cerebral complica- 
tions differ somewhat according to the particular cause. In the 
cases due to injury during birth, well-marked asphyxia is often 
present, from which the child is with difficulty resuscitated. He 
remains torpid, respiration is apt to be slow and irregular, and 
the pulse is feeble. The pupils may be contracted, and the 
anterior fontanelle tense. He does not cry, and evinces little 
interest in the breast. Usually in a few days convulsions make 
their appearance ; but in between these the muscles may still 
remain rigid, and opisthotonos may even be present. At a some- 
what later period paralysis may be noticed. Sitting up, walking, 
and first attempts at speech, are all delayed, and it is gradually 
borne in upon the parents that the child's mind is not quite the 
same as that of other children. In the milder cases the initial 
symptoms may rapidly pass off, and it is only when the child 
begins his schooling that deficiency is noticed, and that he is 
found to be unable to make any mental effort. 

Many of these children are small and delicate, and there is no 
doubt that a large proportion die in the early years of life, some of 
convulsions, others of ordinary children's ailments. But others 
thrive and get fat, and may live for many years ; and it is these 
who come under notice on account of their mental defect. There 
is not, as a rule, any pronounced sensory disturbance, although 
sometimes hearing is impaired. The amentia varies from a mild 
degree of imbecility to gross inarticulate idiocy. If paralysis is 
present, it is generally a paraplegia, and the arms are rarely 
involved in these cases which date from birth. The affected legs 
are small, short, ill-nourished, and their muscles exceedingly 
ill-developed. They may be strongly adducted, and at times 
quite crossed in a sartorial posture. Contractures are often 
present, and the reflexes are usually much exaggerated. In some 
cases the paralysis is slight, and consists simply of weakness and 
dragging of the limbs, with some rigidity and increased reflexes. 
Exceptionally it is absent altogether. 



Secondary Amentia and its Clinical Varieties 209 

In those cases which arise during the first few years of life, either 
in the course of, or as a sequel to, one of the specific fevers, or 
as a cerebral inflammation apart from any previous illness, the 
symptoms are slightly different. The first indications of an affec- 
tion of the brain are often malaise and vomiting, and these are fol- 
lowed by restless delirium or unconsciousness, fever, convulsions, 
and often paralysis. The fact that the onset of many of these cases 
is so often attended with convulsions causes them to be frequently 
designated "epileptic" or "eclampsic" amentia, whereas the 
convulsions are in reality a symptom and not a cause. They are 
sometimes very severe, and may recur with great frequency for 
several days. The temperature rarely rises to more than 102 F. 
Paralysis may be noticed at the onset, or it may not appear until 
a few days afterwards. It may even be absent entirely. When 
present it usually consists of monoplegia or hemiplegia ; diplegia 
is rare. The reflexes are increased, but there is rarely any 
marked disturbance of sensation. In course of time the fever 
abates, the convulsions cease, or continue only at rare intervals, 
the child recovers consciousness, and some amount of improve- 
ment takes place in the paralysis. But the psychic functions 
have been damaged ; in some cases an obvious impairment of the 
intellect is noticed immediately, in others only as the child begins 
to get about and mix with his companions. If he had begun to 
speak, he may be now speechless. The playmates and games of 
which he was formerly fond now cease to attract him. His whole 
behaviour and disposition may be so altered that the parents 
remark upon the change. As time passes, it is found that his 
capacity for learning has been interfered with, and it is soon 
evident that the illness has resulted in a more or less serious 
arrest of mental development. 

In view of the widely differing ultimate effects of these cerebral 
lesions, it is obvious that no accurate forecast is possible. Of the 
children born with asphyxia, the number in whom amentia results 
is exceedingly small, and careful observation of the child for a few 
days will usually enable the physician to reassure the parents on 
this head. Of the cases happening during early childhood, the pro- 
portion who become aments is much larger, and this possibility can 
never with certainty be excluded until the lapse of some time after 
the illness. If paraplegia be present (which, however, is relatively 

14 



210 Mental Deficiency- 

rare), then it is highly probable that some degree of mental 
deficiency will result. Apart from this, however, the degree of 
paralysis affords no indication as to the amount of psychic damage. 
There may be extensive hemiplegia with no intellectual defect, 
or there may be profound amentia with but trifling or even no 
paralysis at all. Even were one able to exclude all involvement 
of the psychic areas, there would still be the possibility of recurrent 
epilepsy, and the consequent induction of amentia and dementia. 

The mental deficiency in these cases may be slight or severe. 
Some patients are merely feeble-minded, and beyond a general 
simplicity and childishness, an inability to get on at school and to 
fend for themselves, they are capable of a considerable amount 
of useful work under supervision. Others belong to the imbecile 
grade, and are capable of very little ; others are idiots. In some 
persons the defect seems to be more particularly marked in certain 
faculties ; thus, we find that in some the memory is chiefly 
affected, in others the attention or the power of speech. In dis- 
position and behaviour some of these aments are placid, contented, 
affectionate, and trustworthy, but others are very emotional and 
undependable. I am inclined to think that a suspicious dispo- 
sition and general irritability of temper, together with a liability 
to be easily upset and to commit impulsive actions, are very 
common characteristics of patients suffering from this variety of 
amentia. As already remarked, there are no stigmata of 
degeneracy, and in the majority of these persons the bodily 
development and nutrition are normal. Often, indeed, as 
Langdon Down said, they are of winsome and comely appearance. 

It is impossible to formulate more than very general rules 
as to the prospects of improvement in these cases. On the 
whole, if the case is really a secondary one, and not a case 
of primary amentia complicated by a gross cerebral lesion, and 
if convulsions are not frequent, there is a likelihood of a fair 
amount of improvement under proper educational methods. 
But such training must be begun early to be of much avail, and, 
unfortunately, one finds a very great tendency to postpone it 
until too late, under a mistaken trust that the child will " grow 
out of it." The extent of paralysis is no criterion as to the 
possibility of improvement. Some of the most hopeless cases are 
those in whom there is no paralysis, whilst some of those who 



Secondary Amentia and its Clinical Varieties 2 1 1 

suffer from a severe physical handicap may be taught to perform 
really useful work. Recurring convulsions are of much more 
unfavourable import. 

Paralytic Aments. — In a large proportion of these cases paralysis 
is present, and such are often described as paralytic aments. 
But the association is not invariable, and it is more correct to 
look upon the paralysis as a symptom or complication, albeit a 
frequent one. The amount of paralysis varies enormously, 
ranging from a partial monoplegia to a hemi- or (rarely) para- 
plegia. In some cases the only observable defect may be a 
want of opposition of the thumb of one side. In others there is a 
severe hemiplegia, accompanied, it may be, by some weakness 
of the opposite foot. In the traumatic or asphyxial cases, double 
talipes equino -varus is not uncommon ; both legs may be com- 
pletely paralyzed, and occasionally spastic paresis of the legs may 
be accompanied by an inability to perform certain fine move- 
ments of the hands. As a rule, the face and tongue are not 
involved. The muscles affected are those concerned in the 
performance of definite movements, and they usually become 
considerably atrophied ; but there is no reaction of degeneration. 
In course of time rigidity and shortening take place, with the 
development of contractures and abnormal postures. The 
reflexes are usually exaggerated, and Babinsky's toe sign is 
frequently present. In fact, the grouping and general features 
of the paralysis are characteristic of a lesion of the upper efferent 
pathway. In some cases, however, I am inclined to think it may 
descend so as to involve the lower spinal tract. 

In other cases convulsions are a prominent feature, and these 
may occur with or without paralysis. As a rule, in their onset, 
course, and post-convulsive state these are indistinguishable 
from those of ordinary idiopathic epilepsy ; but in some cases 
they are of a Jacksonian character. In one of my patients both 
localized and general convulsions occurred, the former un- 
attended by loss of consciousness ; but they gradually passed into 
the typically epileptic variety, and I think this is the tendency in 
most of these cases where the fits begin as Jacksonian. Some- 
times paralysis may exist for years without any fits, and then 
epilepsy suddenly makes its appearance. Petit mal also occurs. 
In a few cases there is seen a constant rhythmic tremor or 

14 — 2 



212 Mental Deficiency 

irregular choreiform movements without epilepsy. As already 
mentioned, those cases the origin of which is marked by a series 
of convulsions are often described as eclampsia amentia, whilst 
those in which the fits continue, and have the characters of 
epilepsy, are spoken of as epileptic amentia. In my opinion, 
however, this latter term should be restricted to cases of amentia 
due to idiopathic epilepsy without a gross lesion. 

Illustrative Cases. 

Medium-Grade Amentia, with Hemiplegia and Convulsions, the 
Result of a Birth Injury. — M. B., female. No family history 
obtainable. The patient has had fits and paralysis since a baby, 
supposed to be due to an injury at birth. She went to school for 
a few years, but could never learn. At twelve years of age was 
admitted into workhouse in consequence of death of parents. 
Was thence sent into the asylum owing to epileptic fits. She is now 
twenty-two years of age, and has been under my observation for 
two years. She is a placid, simple-looking girl of apparently 
seventeen years or so, rather small, but well-nourished, and 
devoid of stigmata of degeneracy. There is left hemiplegia 
involving the leg, arm, hand, and lower part of the face. The 
reflexes are exaggerated on both sides, and there is slight lateral 
nystagmus. No impairment of sensation can be made out. 
She is subject to convulsive attacks without loss of consciousness, 
the duration of which has been as long as two hours. These 
consist of clonic movements of the left (paralyzed) hand and 
arm, with twitching of the left corner of the mouth, and drawing 
of the head to the left side. During the attack the knee-jerks 
are exaggerated (particularly the left), but there is no ankle clonus, 
and the pupils are norma]. She says that the attacks are pre- 
ceded by a " feeling " under the left arm, and that whilst they 
last she feels pins and needles in the left face, arm, and leg. 
Some of these attacks are followed by a state of general rigidity, 
with loss of consciousness. In addition she has petit mal and 
convulsions which are typically epileptic. Her mental con- 
dition is that of a high-grade imbecile. She can carry on a 
simple conversation, but does not volunteer information, and she 
will agree to almost anything suggested to her. She cannot read, 



Secondary Amentia and its Clinical Varieties 213 

but can just scrawl her name. She can count up to thirty, but 
cannot say what two and two make. She will do what she is told, 
and helps in the ward-cleaning. Her memory is poor ; she has no 
idea of time or dates, but her attention is tolerably good. She 
is occasionally mischievous and takes things from the other 
patients, but on the whole is well-behaved and gives little 
trouble. 

Amentia with Double Talipes due to Asphyxia Neonatorum. — 
M. i 7 ., female. There is nothing abnormal in the family history. 
The patient is the fifth of a family of ten ; two died in infancy? 
the remainder are healthy. The mother tells me that M. F. 
was a very large child, that the labour was very prolonged, and 
that she was so blue and lifeless at birth that the doctor in 
attendance had to make " an opening in her throat." I do not 
know what this could have been, and can find no evidence (at 
seventeen years of age) of any tracheotomy scar ; but there 
seems little doubt that the child had severe asphyxia neona- 
torum. The mother says she was quite " dummy " from birth, 
and utterly different to the other children ; that she had severe 
fits whilst cutting her teeth, did not walk until four and a half 
years, and never said a word until she was in her sixth year. She 
went to school, but could not learn, and she afterwards had 
several situations, but could not keep them, as she seemed too 
simple and childish. At the age of seventeen years she began to 
get very troublesome and spiteful ; she was considered a danger 
to the younger children, and sent to the asylum. 

Upon admission she was a fairly well-grown girl, with a de- 
cidedly childish and vacuous expression. There was no observable 
sensory defect. She could understand what was said to her, and 
was capable of replying to simple questions. She could read and 
write words of one syllable, and could add up to ten. On the 
whole she was quiet and well-behaved, and did a certain amount 
of work in the laundry under supervision ; but she had no power 
of reasoning, and was obviously far too deficient to earn her 
living. She was of a remarkably facile disposition, and readily 
assented to any proposition made to her ; she also had a consider- 
able defect in the power of sustained attention. Speech was 
exceedingly indistinct. She had double talipes varus, with some 
dragging of the feet in walking, but no other signs of paresis. She 



214 Mental Deficiency 

is now nineteen years of age. She has had no fits since childhood, 
but her mental deficiency is becoming more marked. She is at 
times rambling and incoherent in her conversation, but is on the 
whole well-behaved and gives no trouble. The slight paresis of 
the feet is somewhat more pronounced than formerly, and the 
knee-jerks are exaggerated. 

A mentia due to Traumatic Epilepsy. — S. V. , female. The patient 
is the sixth of a family of ten ; two sisters died in infancy, but the 
remainder are well grown and quite healthy in body and mind. 
A complete family history was obtained, and revealed an entire 
absence of morbid heredity. 

5. V. was born at full term without any abnormal circum- 
stances. She cut her teeth, walked, and talked at the ordinary 
age, and, in fact, appeared to be a perfectly healthy child until 
four years of age. She then had a fall in the street, striking her 
head against the curb ; she remained unconscious for half an 
hour, and then came to, but seemed dazed. Five weeks after- 
wards she had her first epileptic fit, and they have continued 
almost daily since. 

I saw this girl for the first time at the age of fourteen years. 
She was tolerably well grown for her age, and had no stigmata of 
degeneracy, although quite idiotic in manner and facies. She 
did not understand all that was said to her, but could obey some 
commands by signs. She was incapable of any kind of work, and 
could not dress or feed without help. Constantly wet and dirty. 
Could say a few monosyllabic words, but most of her utterances 
were inarticulate grunts. She was said to be good-tempered and 
quite harmless. On careful examination, I found that there 
was slight dragging with e version of the right foot. The right 
face was also less full than the left, but there were no other 
localizing symptoms. The fits were typically epileptic, and 
followed by a prolonged period of unconsciousness. I came to 
the conclusion that the case was probably one of combined 
amentia and dementia, the result of traumatic epilepsy, and 
although I thought it very doubtful whether anything could be 
done so long after the injury, I recommended operation as a 
justifiable and the only possible measure. 

Mild Amentia, with Paralysis and Convulsions, consequent upon 
" Infantile Hemiplegia." — F. D. W., male. No morbid heredity. 



Plate XVI. 





CV.D 

£.5 



To face page 214] 



Secondary Amentia and its Clinical Varieties 215 

His brothers and sisters are healthy in body and mind, and the 
patient appeared perfectly normal until his second year. He 
then had a severe illness, which left him paralyzed in the right 
hand and arm, and a few years later he was noticed to be more 
simple than other children of his age. He went to school, but 
could never get on, and he cannot read, write, or sum. Upon 
leaving school he used to help his father (who is a publican) in the 
bar, but he has never followed any regular employment. He was 
subject to occasional epileptic fits, and after one of these 
assaulted his father and sister, and became so unmanageable 
generally that he had to be sent to an asylum, where he has since 
remained. 

He is now forty-two years of age, and is a well-developed man of 
medium height, with no stigmata of degeneracy. His facial ex- 
pression is placid and somewhat childish. There is dropping of 
the right wrist, and the interossei as well as the muscles of the 
thenar and hypothenar eminences and forearm are very little 
developed. The whole of the right forearm is short and stunted, 
as compared with the left. He can make use of the affected arm 
for coarse purposes, but he cannot perform fine movements. He 
cannot move the toes of the right foot, and they are cold and blue, 
but there is no other observable paralysis of this or any other 
portion of the body. There is no sensory defect, and he has had no 
fits for several years. 

His memory is only fair, and is better for remote than recent 
events. His power of attention is good, and he has no special 
sense defect. He can carry on a simple conversation, and can 
give a tolerably good account of his past life ; but his general 
intelligence is poor, and he is too childish to take care of himself 
without supervision. He is very suspicious of strangers, and very 
disinclined to answer their questions. He is emotional, and 
readily moved to laughter or tears. He is very variable in 
temper, and at times surly, perverse, and very troublesome, but 
at others he is a not unwilling worker in the dormitories. (See 
Plate XVI., Fig. 41.) 

Mild Amentia with Paraplegia, due to a Cerebral Lesion during 
Birth. — T. W., male, aged thirty-three years. Owing to the 
death of the patient's parents a complete history is unobtainable, 
but, as far as can be ascertained, there is no morbid heredity, and 



216 Mental Deficiency 

the condition is the result of a lesion during birth, which left 
the patient paralyzed in both legs and mentally defective. He 
has been in institutions since childhood, and although he has 
learned to read and write fairly well, and even to do simple sums 
in arithmetic, the absence of any systematic manual training, 
together with his general intractability, cause him to be quite 
unemployed. 

He has an alert, and at times a decidedly cunning, look, and his 
features are of a low animal type, but there are no obvious stigmata 
of degeneracy. The skull is symmetrical and larger than usual, the 
circumference being 23 inches. Both lower limbs are completely 
paralyzed from the thighs downwards ; they are also very small 
and imperfectly developed, blue and cold, and covered with a 
plentiful growth of hair. Tactile sensation is markedly dimin- 
ished in the paralyzed limbs, and the knee-jerks and plantar 
reflexes are absent. Walking is impossible, but the patient is 
very adept at propelling himself along his haunches by making 
use of his hands and arms as levers. There have never been any 
convulsions. 

There is no defect of the special senses. He understands most of 
what is said to him, and can reply, but usually refuses to do so. 
His memory is good ; he is very observant, and capable of simple 
reasoning ; but he cannot follow an argument, and his ideas and 
general behaviour are characterized by a childish simplicity. 
The powers of attention and control are markedly defective. If 
asked to write his name, he takes the pencil in his hand, looks at it, 
and then puts it down to look at his arm. He then takes it up 
again and makes a start, but drops it to scratch his back. 
Another beginning is interrupted to look at some one coming in 
at the door. In fact, he is as inquisitive and curious as a monkey, 
and so distracted by everything happening around him that he 
can settle down to nothing. He is destructive and constantly 
tears up his clothes, and from time to time he has outbreaks of 
noisy violence, during which he uses disgusting language and 
attacks anyone who may be near him. (See Plate XVI., Fig. 42.) 

Amentia with Epilepsy, due to " Sunstroke." — E. S., male. The 
eighth born of a family of nine, all the others being healthy. 
There is a tendency to alcoholism on the parental side, but no 
insanity, epilepsy, or consumption. The patient seemed per- 



Secondary Amentia and its Clinical Varieties 217 

fectly well until three years of age. Dentition had been normal ; 
he was able to walk well, and was making progress with his talk- 
ing. When just turned three he had " what the doctor called 
meningitis " following exposure to a severe sun. The mother says 
that for nine weeks he was unconscious and repeatedly convulsed. 
For twelve months after this he never uttered a syllable ; he 
then began to pick up a few words again, but made little progress, 
and his parents noticed a profound change in him. Usually 
he was dull and stupid, and seemed to have little sense, but at 
times he became violent and unmanageable ; the fits continued 
at short intervals. At the age of nine he became so trouble- 
some that he had to be sent to the asylum. On admission he was 
somewhat undersized for his age, and poorly nourished. His 
features were good, and there were no stigmata of degeneracy, but 
the expression was vacant. Fits occurred daily ; they were very 
severe, preceded by cry, followed by a period of unconscious- 
ness, and had all the characteristics of true epilepsy. He could 
understand what was said to him, and would occasionally reply, 
but as a rule he was moody and silent and resented being ques- 
tioned. He was incapable of any employment. The patient 
steadily became worse. He was a confirmed masturbator and 
addicted to swallowing pebbles. He became wet and dirty, 
required to be fed, and needed constant attention. He took no 
notice of his surroundings, did not seem to understand what he 
was told, and if examined became very resistant and forbidding. 
At times he would sit in a chair flapping his arms and making 
hideous noises ; at others he was moodily silent. He died at the 
age of seventeen years, of exhaustion after a series of fits. 

On making a post-mortem examination, I found the skull very 
thick and dense, the diploe being obliterated. The brain was 
small, and weighed 37 J ounces, the left hemisphere being 
5 J ounces less in weight than the right. The ventricles were 
dilated, and there was considerable excess of clear fluid. The 
membranes appeared normal. The brain was tolerably well con- 
voluted, and presented nothing abnormal externally beyond a 
general diminution of size. On making careful sections, however, 
a localized area of softening, about the size of a filbert, was found 
in the left supramarginal convolution at the junction of the grey 
and white matters. This in all probability was of vascular 



2i8 Mental Deficiency 

origin, and the final result of the attack of encephalitis which 
took place at three years of age. (See Plate XVII. , Fig. 43.) 

Mild Amentia with Motor Aphasia, due to an Infantile Cerebral 
Lesion. — The following is a case of secondary amentia consequent 
upon infantile convulsions (eclampsia) ; it is probable, however, 
that these were the result of some toxic lesion of the brain. 

N. T., male, born in India, the second child of a family of six. 
Parents healthy, and no morbid heredity. Seemed perfectly 
normal until nine months old, when he had a series of convulsions 
lasting three days. These continued, at intervals of a few months, 
until he was three years of age ; they were attended with un- 
consciousness, and in the last attack he was given up by the 
doctor. He recovered, however, and has had no further fits, 
but from that time his parents noticed a great mental change. 
He failed to understand what was said to him, became restless at 
night, exceedingly dirty in his habits, and required constant 
watching during the day to prevent him destroying everything he 
laid his hands on. As time passed some improvement took place : 
he became more manageable, and able to do little things for him- 
self. He would also help his mother in laying the dinner-table and 
similar household duties, but he could not be depended upon, 
was at times very intractable, and was quite unable to speak. 

I first saw him at the age of eleven years. He was a sturdy, 
well-developed boy, with good features but a decidedly vacuous 
expression. There was no sensory defect ; he could understand 
simple commands and remarks ; but he was obstinate, and took 
little notice of anything said to him. He couid whistle, but could 
not articulate, and he was passionate and untrustworthy. As far 
as could be ascertained in the absence of conversation, his general 
intelligence was about equal to that of a normal child of five or 
six years. I came to the conclusion that the case was one of 
mild amentia secondary to meningo -encephalitis of the frontal 
lobes, and involving the motor speech centre, and considered the 
prospect of improvement slight, but recommended special training 
in an institution. This has now been carried out for three years. 
He has improved greatly in habits and general behaviour, he 
is now thoroughly obedient and dependable, and evinces an 
affectionate disposition towards those about him. He is fond of 
manual work, and can perform many kindergarten occupations, 



Plate XVII. 





SI 

2 £ 






To face page 218,] 



Secondary Amentia and its Clinical Varieties 219 

such as plaiting and bead-threading, very well. He lays the dinner- 
plates with a marvellous dexterity. He has learned to make pot- 
hooks and hangers, knows some of his letters, and can count up to 
six. But he finds school work very uncongenial, and cannot settle 
down to it. He seems incapable of making any mental effort. 
He understands all that is said to him, but still remains unable 
to articulate, and, in spite of persistent attempts to teach him, the 
nearest approach to a word he can utter is a guttural " cuckoo." 

In the following case there is slight morbid heredity, but mental 
development proceeded normally until an attack of " meningitis " 
in infancy. The degree of defect is mild, but it is accompanied 
by evidences of instability, which will probably culminate in 
actual insanity before adolescence is passed. 

K. G., male. Was born in India, and has four brothers and 
sisters alive and well. His mother is an exceedingly delicate, 
neurotic woman, his father strongly addicted to alcohol ; but 
there is no history of epilepsy or insanity on either side. The 
patient seemed all right until fifteen months old, when he was 
laid up for two months with some brain illness, accompanied by 
fits, which is described as " meningitis." From this time he 
became subject to fits of irritability, and showed indications of 
mental defect. He went to school at the age of seven, and 
showed a considerable taste for drawing and manual - work ; 
but he was never able to make progress in any studies, and 
seemed incapable of mental application. I saw him in consulta- 
tion at the age of eleven ; he could then read and write simple 
sentences, and was capable of simple addition and subtraction 
sums. He had a good memory, and could recount a few his- 
torical and geographical facts, but his manner was very restless 
and his attention very fitful ; he was quite incapable of settling 
down to school work, and his general intelligence and power of 
reasoning were no greater than those of a normal child of six 
years. Cranial circumference, 2if inches. He was affectionately 
disposed to those about him, but of a very undependable temper. 
Was addicted to hiding up trifling objects of no value, and had 
wandered away from home on several occasions. At times he 
was destructive, and would tear up clothes, toys, and picture- 
books indiscriminately. Occasionally he was noisy and aggres- 
sive, and had attacked those about him. 



220 Mental Deficiency 

Amentia accompanied by Porencephaly or Cerebral 
Hemiatrophy. 

As seen in the post-mortem room, these cases appear to be 
widely different from those just described, in which the patho- 
logical findings are cysts, localized atrophies, softening, meningo- 
encephalitis, and the like. Here we have to do with a condition 
of porencephaly or hemiatrophy of such an extent that the 
affected hemisphere may be 200 or 300, or even more, grammes 
less in weight than the opposite one, and it would seem as if 
such must be accompanied by special clinical features. In some 
instances this is so, and on that account it is desirable to refer to 
these conditions separately. But, on the other hand, it must be 
admitted that these severe conditions can often only be suspected 
during life, and that they are by no means rarely found after 
death when there had previously been nothing to suggest that 
more than a minor pathological disturbance was present. An 
interesting case of this nature has been recorded by Conolly 
Norman and Fraser.* It was that of a very fine female who had 
never been under restraint, and who presented no external 
evidence of extensive brain disease in the shape of atrophy, con- 
tractures, etc., and yet post-mortem there was found extreme 
wasting of one hemisphere, as well as of the corresponding basal 
ganglia. Many similar cases in which the clinical signs have 
been comparatively slight have been recorded by other writers — 
viz., Van der Kolk, Bianchi, Heschl, Spiller, Lambl, etc. 

In most cases these conditions are the result of disease, and 
date from very early infancy, if not from uterine existence ; a few, 
however, seem to be due to primary anomalies of development. 
But the distinction can only be inferred clinically, and not always 
with certainty upon dissection. 

During life an ament may be suspected to be the subject of 
porencephaly or extensive hemiatrophy if there is severe hemi- 
plegia accompanied by contractures and marked non-develop- 
ment of the affected limbs, and if convulsions are also present. 
But, as already remarked, the hemiplegia is often astonishingly 
insignificant, and it rarely involves the tongue or face. The 

* Conolly Norman and Alec Fraser, " A Case of Porencephaly," Journal 
of Mental Science, October, 1894. 



Secondary Amentia and its Clinical Varieties 221 

convulsions are of the usual epileptic type, and are fairly frequent, 
but cases have been recorded in which they were absent. Some- 
times much headache is complained of. The diagnosis is rendered 
more probable if, in addition, there is marked flattening of one 
side of the skull, but in many of these cases the space is filled up by 
excess of fluid or growth of the inner table only. I know of no 
other distinguishing features. The amentia may be of any grade, 
from a mild imbecility to gross idiocy, and stigmata of degeneracy 
may be present or absent according as the case is one of primary 
amentia complicated by these lesions, or one of secondary 
amentia due to them. In the latter dementia often supervenes, and 
death frequently results from tuberculosis or follows a succession 
of fits. Of Kundrat's* series of eighteen cases of porencephaly, 
only three survived the period of infancy. 

Illustrative Cases. 

False Porencephaly with Cystic Formation. — A. E. W.,"f female. 
Imbecile. No morbid heredity. Born paralyzed on right side. 
Constantly suffered from headache and epileptic fits. The 
paralysis involved the right arm and leg, but not the face. The 
affected limbs were smaller and shorter than the sound ones. 
There was talipes equino-varus of the right foot, but no contrac- 
tures. The knee-jerks were absent. Speech indistinct, memory 
poor, depressed and dull mentally. She was subject to frequent 
fits, beginning in the affected side, and then becoming general. 
She gradually became more and more demented, and died at the 
age of twenty-two, after a succession of severe fits. 

The post-mortem examination showed extensive atrophy of 
the lower part of the motor region on the left side, and of the 
corresponding efferent tract in the pons, medulla, and cord. 
The depression in the brain was occupied by a subarachnoid 
cyst. The left ventricle also was greatly dilated. The weight 
of the left hemisphere was 435 grammes, and of the right 
585 grammes. 

Cerebral Hemiatrophy with Ventricular Dilatation. — J. E., male. 

* Op cit. 

I For a fuller description of the histological appearances ii this and the 
following case, see " Hemiatrophy of the Brain," by Mott z id Tredgold, 
Brain, part xc, 1900. 



222 Mental Deficiency 

Fits, paresis of right arm, and weak-mindedness from infancy. 
The right leg also weak, but he was able to walk, and he had 
been engaged as a shoeblack. He was admitted into the asylum 
at the age of twenty-six in consequence of frequent epileptic fits 
accompanied by attacks of noisy excitement. On several 
occasions he had attacked those about him without provoca- 
tion. He gradually became demented, and died, aged thirty, of 
acute phthisis. 

On post-mortem examination the skull was symmetrical 
externally, but there was marked thickening of the whole of the 
inner table on the left side. In some situations the thickness 
was more than twice that of the opposite side. The weight of 
the right hemisphere was 575 grammes, that of the left but 
155 grammes. The left ventricle was hugely dilated, the sub- 
stance of the hemisphere being reduced to a mere shell in places. 
The left basal ganglia, particularly the optic thalamus, were also 
exceedingly small and ill- developed. There was consecutive 
atrophy of the left crus, pyramid and fillet in the pons and 
medulla, with atrophy of the right half of the cerebellum and its 
superior peduncle. There was also sclerosis of the left direct 
and right crossed pyramidal tracts in the cord, of the left antero- 
lateral column, and marked numerical diminution of the anterior 
horn cells in the cervical and lumbar regions. 

The following description, by Dr. Ross, of a case of double 
true porencephaly (which is exceedingly rare) is quoted by Ireland : 

" The patient was a little girl who died of croup at the age of 
two years and five months. At the age of three months her 
parents first observed that she could not hold her head up, and 
that her hands were stiff. She never at any time suffered from 
convulsions. The child was small for her age, but fairly 
nourished. The legs were kept in a half-flexed condition, the 
feet extended, and the heels drawn up. The arms were held 
semi-flexed in a symmetrical position. The muscles of both 
extremities were in a state of spasmodic rigidity. Any attempt 
to alter by passive motion the position of the limbs caused 
increased spasmodic contractions. The head was kept bent 
forwards, the chin upon the sternum ; but she could raise her 
head by ai effort, soon again to fall into the old posture. She 
could voluntarily grasp an object with each hand, but the move- 



Secondary Amentia and its Clinical Varieties 223 

ments were irregular and uncertain. She could only utter a few 
monosyllables." 

" On examination after death a deep sulcus was found in each 
side of the brain, about the site of the fissure of Rolando, extend- 
ing from the point of bifurcation of the Sylvian fissure for about 
ij inches upwards. Each sulcus opened into the corresponding 
lateral ventricle by an aperture the size of the little finger. Each 
opening was surrounded by a ring of grey matter having all the 
naked eye appearances of the cortex. The ascending frontal and 
ascending parietal appeared to be absent, and the surrounding 
gyri were displaced. The crura cerebri, pons and medulla 
appeared quite normal to the naked eye." Microscopical 
examination showed that the cortex contained a number of 
imperfectly developed cells almost destitute of processes. The 
anterior pyramids of the medulla also were not more than half 
the size of those of a normal child of corresponding age, and the 
lateral columns of the cord were also diminished in size. 

Bourne ville* has recorded six cases of cerebral hemiatrophy, 
of which the following are synopses. All the patients were 
imbeciles or idiots, and almost all suffered from epileptic con- 
vulsions, and showed post-mortem sclerosis, atrophy, and chronic 
changes in the membranes and brain tissue. 

1. Pseudo-porencephaly. Fifteen years old. Left hemiplegia 
with epilepsy. Right hemisphere, 240 grammes. Left hemi- 
sphere, 560 grammes. 

2. Imbecile. Twenty-one years. Right hemiplegia and 
epilepsy. Right hemisphere, 465 grammes. Left hemisphere, 
185 grammes. 

3. Imbecile. Eleven years. Left hemiplegia and epilepsy. 
Left hemisphere, 570 grammes. Right hemisphere, 310 grammes, 
showing pachymeningitis and meningo-encephalitis. 

4. Idiot. Four and a half years. Right hemisphere, 
460 grammes. Left hemisphere, 200 grammes, with marked 
sclerosis. 

5. Imbecile. Thirteen years. Right hemiplegia. Right hemi- 
sphere, 665 grammes. Left hemisphere, 455 grammes. 

6. Idiot. Ten years. Right hemisphere, 477 grammes. Left 
hemisphere, 255 grammes. 

* Bourneville, Progr&s Medical, 1898, p. 248. 



224 Mental Deficiency 



SCLEROTIC AMENTIA. 

It has already been remarked that proliferation of neuroglia, 
resulting in sclerosis, is found post-mortem in a considerable 
number of cases of both the primary and secondary forms of 
amentia.* In many of these it is a pathological condition, which 
has no clinical significance, and gives rise to* no definite symptoms 
by which its presence may be diagnosed, or even suspected, 
during life. In a small proportion of cases, however, the neurog- 
liosis attains such magnitude as to produce a tolerably readily 
recognizable type of amentia, and these we shall here describe. 

Regarding the etiology of these cases our knowledge is .still, 
imperfect, and it is probable that the same result may be produced* 
by different causes. In many — indeed, I think, in the majority 
of cases — inquiries into the family history seveal the presence of 
alcoholism, phthisis, insane and epileptic heredity, , precisely the 
same as in ordinary cases of primary amentia^, but in addition 
there is often a history of birth injury or other vascular or toxic 
lesion of early infancy which may possibly act as a determin- 
ing influence. In a few cases the latter conditions alone are 
present. But although it seems probable that in the majority of 
cases sclerosis is determined by, and the after-effect of, some 
diseased (vascular or toxic) condition^of the brain, it may in a 
small number of instances arise independently of such conditions 
in consequence of primarily imperfect neuronic development. 
However produced, and whether the amenjja -be a ^primary one 
complicated by sclerosis, or whether the sclerosis is itself the 
cause of the amentia, the result is pretty much the same. And 
since the special clinical symptoms in these cases are in the main 
referable to the sclerosis, and since, moreover, the cases resemble 
many of the pure secondary forms in their tendency to degenera- 
tion and dementia, it seems, on the whole, preferable to describe 
sclerotic amentia in this place. 

There are two chief clinical types of this variety of amentia, 
dependent upon whether the sclerosis is general and diffuse, or 
occurs in localized patches. This division is, perhaps, not an 
absolute one, and cases of diffuse sclerosis have been described in 

* See Chapter IV., Pathology. 



Secondary Amentia and its Clinical Varieties 225 

which the condition was confined to one hemisphere. Neverthe- 
less, there are certain clinical differences in the two forms which 
sufficiently justify such a distinction. 

In cases of diffuse sclerosis the dominating symptoms are 
general muscular weakness, often accompanied 'by spastic rigidity 
and feeble contractures, but rarely by actual paralysis. There 
is also marked tremor, but not often definite convulsions. In , 
localized, nodular, or tuberous sclerosis, on the other hand, there 
are usually frequent epileptic fits without paralysis or contrac- 
tures, although movements are often tottering and tremulous, and 
in these latter cases death often results from a succession of fits. 

Extensive gliosis, in the first instance, produces an enlargement 
of the brain, and in this way gives rise to a clinical variety of 
amentia, which is known as "hypertrophic." With the lapse of 
time, however, the neuroglia tends to contract, and there is then 
produced a regular or irregular form of bram atrophy. The 
hypertrophic brain never tends to indefinite enlargement as does 
the hydrocephalic, and the effect of time in bringing about con- 
traction of the glia tissue is well seen in the central umbilication 
which takes place in the tuberous areas of the localized form. 
This feature of the neuroglia is seen in other diseases ; for in- 
stance, the spinal cord in the early stage of extensive disseminated 
sclerosis is greatly swollen, whilst in the later stages it becomes 
exceedingly small, shrivelled, and distorted. 



Diffuse Sclerosis. 

Cases of amentia accompanied by diffuse sclerosis fall into 
two groups, dependent upon whether cranial enlargement is or 
is not a prominent feature. We may therefore describe atrophic 
and hypertrophic forms. But, as already stated, it is doubtful 
whether there is any essential pathological difference between 
these two forms, and the clinical difference is probably dependent 
upon the extent and rapidity with which neuroglial increase takes 
place whilst the cranial bones are yet ununited. Where synostosis 
has not occurred, so that expansion of the skull may allow of 
cerebral enlargement, the prognosis as to life and response to 
training is much more favourable than where the bones offer an 
unyielding resistance. 

15 



226 Mental Deficiency 

(a) Atrophic Form. — These cases are very rare. In those 
hitherto recorded the mental deficiency has usually been of a 
pronounced grade, and although there may be some slight re- 
sponse to training at first, progressive dementia supervenes sooner 
or later. Definite convulsions are uncommon, but a condition 
of muscular tremor is always present. This varies from a more 
or less constant shaking of the head to an incessantly repeated 
fine tremor of the whole body. It is increased under observation 
or voluntary effort, and is often described as chorea ; but it is 
more akin to the tremor of paralysis agitans. In addition there 
is a general muscular weakness, with spasm and incomplete con- 
tractures of the arms or legs, but there is rarely actual paralysis. 
The reflexes are increased. In some cases both epileptic convul- 
sions and paralysis ai e present, and Bourneville* has described a 
case in which these were at first limited to one side of the body ; 
but at the age of thirteen classic epilepsy appeared, and the 
patient died, aged twenty-one, in status epilepticus. The post- 
mortem examination showed atrophy and sclerosis of the whole 
of one hemisphere. 

Illustrative Cases. 

Diffuse Sclerotic Amentia with Progressive Dementia.^ — E. G., 
female, was admitted to Darenth Asylum at the age of twelve 
years. No history obtainable. Her mental status was that of 
an imbecile, but sight and hearing were good, and she possessed 
a good memory for faces. Speech was very scanty, and was slow 
and hesitating. Habits cleanly. She was described as a cripple, 
but not paralyzed. There was general muscular weakness of all 
the limbs, so that she was unable to wash, dress, feed, or do 
anything for herself. In addition there was a slight shaking 
movement of the head. She spent all her time sitting in a chair, 
but she noticed what went on round her. The cranial circum- 
ference was 19 J inches. 

After a time the shaking movements of the head increased, and 
eventually extended to all the limbs. There were, however, 

* Bourneville, "Sclerose Cerebrale Hemispherique," Archives de Neuro- 
logie, 1897, vol. iii. 

f For the clinical notes of this case I am indebted to Dr. F. R. P. Taylor, 
formerly Medical Superintendent of Darenth Asylum. 



Secondary Amentia and its Clinical Varieties 227 

never any definite convulsions. The muscular helplessness 
also increased, and the arms and legs became slightly con- 
tracted at the elbows and knees respectively. She became 
duller mentally, less observant, and wet and dirty in her habits. 
Finally her temperature suddenly ran up to 104 F., and her pulse 
to 180, and she gradually sank and died without any signs of 
disease other than the cerebral sclerosis. Her age at death was 
twenty years. 

Post-mortem examination failed to reveal disease of any organ 
other than the brain. The dura mater was thick and congested ; 
the pia thick and opaque, but non-adherent. The whole brain 
was small, but heavy for its size, weighing 32 ounces. Its con- 
sistence was extremely dense — in fact, almost like cartilage. 
Upon making a microscopical examination I found that the whole 
of the hemispheres, the white as well as the grey matter, were 
the site of a dense diffuse sclerosis ; the cerebellum was similarly 
involved. 

The following very similar case is described by Dr. O. 
Heubner : * 

The patient, a boy of five years, seemed bodily and mentally 
sound until the age of three and a half years, except that he was 
late in learning to speak, and could not talk fluently. The family 
was said to be healthy. Apparently as the result of, or at any 
rate after, a fall on the back of the head, he no longer played 
willingly, and was often apathetic. Nine months afterwards 
appeared a slothfulness of all movement, and his walk became 
staggering. This was followed by spastic paralysis of. the legs, 
with contractures at the hips and knees, and double equino- varus. 
Strong intention tremors then appeared in the arms, also followed 
by spastic paralysis. There was difficulty in swallowing, so that 
he could only take liquids, and eventually he became unable to 
speak. There was constant movement of the head and upper 
extremities, and there was slight paresis of the lower part of the 
right face. He became progressively weaker in mind, but able to 
recognize people he knew, and there was no observable alteration 
in general or special sensation. The knee-jerks were increased, 
electrical reactions normal, and there was incontinence of urine 

* O. Heubner, " Ueber diffuse Hirnsklerose," Chariti-annalen, 1897, 
xxii. 

15—2 



228 Mental Deficiency 

and faeces. He became much emaciated, and died of broncho- 
pneumonia. 

Post-mortem examination revealed a pale-yellow brain of 
unusual hardness throughout, the white and grey substances, as 
well as the cerebellum, being extensively involved by sclerosis. 

The two following cases of brother and sister, who were kindly 
shown to me at Darenth Asylum by Dr. F. R. P. Taylor, are 
probably examples of diffuse cerebral sclerosis. 

The mother of these patients is healthy, but the father is insane 
in an asylum. The father and mother are first cousins ; the 
mother's father and mother were also first cousins. There have 
been fourteen children born in the family — five are dead and 
nine living ; there is " something the matter with all of them," 
and at least one other is mentally defective. 

Rose, the eldest patient, was born prematurely at the seventh 
month, and she has been abnormal from birth. She commenced to 
say a few words when about two years of age, and made attempts 
to walk at three ; but she never made much progress, and at the 
age of twelve years, on account of the mental deficiency and con- 
stant tremor, she was sent to the asylum. She proved uneducable, 
and the tremor steadily became worse. When I saw her at the 
age of twenty-one years she was a bright -looking girl, apparently 
quite happy and contented, but of markedly limited mental 
power. She understood a good deal of what was said to her, and 
made attempts to reply ; but her articulation was quite unin- 
telligible on account of the tremor. She spent the day sitting in 
a chair, and was quite unable to walk, or even stand, without 
support. There was spastic rigidity, with inversion and adduc- 
tion of both legs and feet ; the knee-jerks and plantar reflexes 
were exaggerated, and ankle clonus was well marked. The head 
was never still in consequence of constant rhythmic up-and-down 
and side-to-side movements ; the facial muscles were also affected, 
giving rise to a never-ending series of extraordinary grimaces. 
These movements were described as chorea, but they really had 
greater resemblance to paralysis agitans. They were worse 
under observation, but ceased during sleep. 

The brother, William, was very similar, except that in his case 
the rhythmic movements affected the whole body — head, face, 
arms, hands, and legs. It was impossible for him to pick any- 



Secondary Amentia and its Clinical Varieties 229 

thing up, or to retain anything in his hands, but the grasp of the 
hands showed that tolerable muscular strength was present. 
He understood what was said to him, and attempted to reply, but 
his words were quite unintelligible. He had a moderate amount 
of intelligence, and obviously observed what was going on round 
him, and he was quite clean in his habits. 

(b) Hypertrophic Form. — This condition is sometimes described 
as hypertrophy of the brain, but it is to be borne in mind that the 
hypertrophy concerns the interstitial tissue only, and not the 
cerebral neurones — that it is, in fact, a (probably diffuse) gliosis. 

Hypertrophic amentia is relatively rare, and is characterized 
by an enlargement of the brain and skull and by certain bodily 
and mental symptoms. The largest skull of this variety I have 
seen had a circumference of 25 inches. Owing, however, to an 
increase in the density as well as the size, the brain weight is 
often considerably greater than would be expected even from 
the size of the skull. Dr. Fletcher Beach found the brain of a 
boy who died at the age of fifteen to weigh 62 ounces. Dr. Ireland 
quotes two cases described by Dr. Daniel Brunet. The brain 
of one, at the age of seventeen, weighed 1,632 grammes ; that of 
the other, dying at the age of eighteen, weighed 1,780 grammes. 

Owing to the cranial enlargement, these cases are sometimes 
mistaken for hydrocephalus ; but, as pointed out by Dr. Fletcher 
Beach, there are readily recognizable differences. The skull of 
the hypertrophic ament tends to be square in shape instead of 
round, and there are sometimes well-marked frontal prominences. 
In hypertrophy, the greatest circumference is at the level of the 
superciliary ridges, whereas in hydrocephalus it is greatest over 
the temples. Thus, although the skull of the hypertrophic 
patient looks massive, it has not that " top-heavy " appearance 
so characteristic of the hydrocephalic. Further, in hydro- 
cephalus there is usually bulging of the fontanelle and sutures, 
whilst in hypertrophy this is not generally the case ; in fact, the 
expansile effects and the tendency to distend the skull seem to 
be much greater in the former than in the latter condition. The 
cranium, having reached a certain limit, ceases to further expand, 
in consequence of the contraction of the neuroglia ; whilst hydro- 
cephalus tends to expand the skull indefinitely. 

Hypertrophic amentia is usually accompanied by headache, 



230 Mental Deficiency 

which may be very severe, and by epileptic fits. In some cases 
the fits diminish in frequency and severity, and they may entirely 
cease. In others they get steadily worse, and many patients 
ultimately die of exhaustion following a series of fits. In a con- 
siderable number there is a general muscular weakness of all 
parts of the body, so that the balance is unsteady, the walk slow 
and tottering, and the grasp feeble. Tremor is often brought 
out by exertion. In consequence, manual work is performed 
slowly, clumsily, and with considerable difficulty. Speech is 
often similarly affected. Most of the cases I have seen have 
been somewhat undersized, heavy-looking and of good bodily 
nutrition, also of cheerful although somewhat simple expression. 
The degree of mental defect varies very much, and seems to 
be dependent upon the frequency with which convulsions occur. 
Where these are slight, it is usually one of mild imbecility, or 
even merely feeble-mindedness ; but if the fits are at all fre- 
quent, a condition amounting to idiocy may be present. Attacks 
of rage and violence have been described, but these are by no 
means constant, and I doubt whether they are any more common 
in this than in other varieties of amentia. Certainly some of 
these persons are harmless and thoroughly good-tempered. The 
severe cases, w T hich are accompanied by frequent fits, seem to 
die early, and, as far as one can judge from the cases which have 
been recorded, few survive long after maturity. This, however, 
is by no means so with the milder forms, in whom fits are com- 
paratively rare, and at the present time there is one of these 
patients in Earlswood Asylum who is fifty-two years of age, and 
seemingly in excellent health. 



Illustrative Cases. 

W. C. T., male ; the only child ; no morbid heredity. He 
seemed in every way normal until three years of age, when he 
had an acute illness, which the mother calls " influenza and 
rheumatic fever." It was accompanied by fever and very great 
pain in the head. He went to school at the age of seven, and 
left at fifteen. Was in the fourth standard, but his mother 
admits that he was very dull at learning, and does not think 
he was equal to fourth standard work. He had whooping-cough 



Secondary Amentia and its Clinical Varieties 231 

at the age of nine, which was accompanied by six fits. There 
were no further fits until twelve years of age, but during this 
time he was noticed to be very unsteady in standing and walking, 
and he would frequently fall down both in and out of school. 
In addition to being somewhat dull, he was prone to outbreaks 
of bad temper and irritability, and was at times spiteful. The 
head was first noticed to be larger than usual after the attack of 
whooping-cough at nine years. 

I first saw him when he was fifteen years of age. He was 
undersized, but fat and heavy. The circumference of the skull 
at the level of the supra-orbital ridges was 23 inches ; there was 
no asymmetry and no prominences ; the fontanelles were closed. 
The upper and lower jaw-bones were also larger than usual, 
and as a result there were large gaps between the teeth. The 
teeth themselves were poorly developed, and many were decayed. 
The palate was broad and shallow. The nose was strikingly 
broad, with prominent fleshy nostrils ; the lips were thick and 
fleshy, and the mouth large. The tongue appeared quite normal, 
but was always protruded markedly to the right side. There 
was nothing abnormal about ears or eyes. The external genitals 
were well developed, and there was an abundance of pubic hair. 
There was considerable rigidity of the hands, arms, and legs. 
No actual paralysis was present, but the left hand, arm, and leg 
were definitely weaker than the right, and he walked with a 
well-marked limp. The knee-jerks could not be obtained, but 
both plantar reflexes were exaggerated, particularly the left. 
Whilst under examination there were almost constant irregular 
jerky movements resembling chorea ; these also were most 
marked on the left side. He was subject to tonic convulsions, 
averaging four or five daily. During these the right eye was 
firmly closed and the face drawn to the right, the left eye being 
open. Legs and arms were rigid and drawn up on to the trunk. 
No clonic movements and no loss of consciousness. There were 
no sensory defects, memory was good, attention rather fitful. 
He understood all that was said to him, and could converse quite 
rationally, although his speech was thick, slow, and hesitating. 
He used to stutter a great deal, but not now. He could read 
and write, but was exceedingly poor at sums. He had con- 
siderable moral and religious sense, and was obedient and 



232 Mental Deficiency 

well-behaved. His mental status was one of mild feeble- 
mindedness. 

He is now twenty-one years of age, and has been under my 
observation for six years. At the present time the cranial cir- 
cumference over the supra-orbital ridges is 23! inches, over the 
brow 23! inches. His height is 5 feet, weight 9 stones, and there 
is practically no alteration in his appearance. There have been 
no convulsions for several years, but if he gets upset or excited 
the hands and arms become rigid and are drawn up on to the 
chest. His walk is slow and somewhat tottering, and his balance 
is unsteady ; but if he is allowed to take his time he can walk 
several miles. He can do odd jobs, and can clean a pair of 
boots, but it takes him an hour to do so. If he is hurried a 
general muscular tremor sets in, which makes work impossible. 
His hand-grasps are fairly good ; the legs are spastic. He fre- 
quently complains of headache, which he refers to the parietal 
eminences. There is a decided improvement in his mental con- 
dition, and he can do many small jobs about the house. He 
can carry a parcel or a message, but his mother says that he 
cannot be trusted to do shopping, as he gets into a hopeless 
muddle with the change. His temper is irritable and perverse 
at times, but on the whole he is obedient and gives no trouble. 
I have got him into several situations, but he has been 
discharged from each in turn in consequence of his general 
incompetence. 

It is worthy of note that the increased size of the jaws, with 
the separation of the teeth and the large and broad nostrils, give 
rise to a physiognomy somewhat resembling acromegaly. There 
are, however, no other signs of that condition, and the early 
onset is totally unlike it. It is quite possible, however, that the 
signs which are present may be due to a partial sclerosis of the 
pituitary gland. 

I have quoted this case somewhat in detail because it seems 
to me to be a very typical example of that form of hypertrophic 
amentia in which fits have not produced serious mental degrada- 
tion. At the present time there is a very similar case in Earls- 
wood Asylum, and another patient of this type whom I have 
known for over ten years has managed during that time to earn 
his keep as a tradesman's boy. In this case, however, the 



Plate XVIII. 
SECONDARY AMENTIA DUE TO SCLEROSIS. 




Fig. 45. — A case of so-called "hypertrophy of the brain." Age, 21 years. 









.^r^ 










m s 












m '& ** 






E .. ;>:,•' W^ 









Fig. 46. — Hydrocephalic and microcephalic imbeciles. 
To face page 232.] 



Secondary Amentia and its Clinical Varieties 233 

amentia is less marked, and his employer has treated him with 
considerable indulgence. 

Tuberous or Nodular Sclerosis. 

In this form of sclerosis convulsions are usually the first 
symptom to attract attention, being noticed towards the end of 
the first year. In a few cases, however, they are preceded by 
irregular muscular twitching or head-nodding. They continue 
during the life of the patient with tolerable frequency, in some 
cases occurring daily, in others at intervals of a few days. They 
are indistinguishable from ordinary idiopathic epilepsy, and 
minor attacks often occur as well. Mental impairment is noticed 
in the early years of life, and varies from a condition of mild 
imbecility permitting of some training, to a more pronounced 
imbecility or idiocy ; usually it is of a severe grade. Headache 
is often present, and attacks of excitement, rage, and destructive- 
ness are common. Muscular tremor is usually present, and the 
balance may be unsteady and the gait tottering ; but definite 
rigidity and contractures, like those met with in the diffuse 
variety, are absent. There are no sensory disturbances. Pro- 
gressive dementia supervenes, and death usually takes place in 
status epilepticus before the age of maturity. 

Illustrative Cases. 

W. S., male. Father insane ; father's mother epileptic and 
insane. The patient has been subject to epileptic fits since a 
year old. He has always been of deficient intellect, and was 
unable to learn at school. He was subject to attacks of excite- 
ment and violence, and, according to his mother, would take 
up a knife to anyone on the slightest provocation. At the age 
of thirteen he became so troublesome that he had to be sent to 
the asylum. On admission he was found to be a pronounced 
imbecile, possessing numerous stigmata of degeneracy. He 
understood what was said to him, and was able to converse, 
but in a very simple and childish manner. He had a great 
fancy for drawing, but no ability. He was subject to frequent 
epileptic fits and occasional paroxysms of excitement. There 
was no paralysis. His memory gradually became defective and 



234 Mental Deficiency 

his articulation indistinct. Salivation was constant. He became 
more and more demented, and died at the age of nineteen from 
exhaustion consequent upon status epilepticus lasting seven days. 
During this time he had 406 convulsions. 

Post-mortem examination showed a dense, thick, symmetrical 
skull, with a small but heavy brain, which weighed 1,445 grammes. 
The membranes appeared normal, and there was no excess of 
cerebro-spinal fluid. Both hemispheres were studded with 
numerous protuberances of pale sclerotic tissue, from which the 
pia arachnoid stripped with unusual readiness. These nodules 
varied from the size of a pea to that of a small walnut ; many of 
them were extremely hard to the touch, and such were marked 
by a central umbilication, evidently due to contraction. They 
were strictly confined to the grey matter, the most careful 
examination failing to reveal them in the centrum ovale. 
Histologically, these nodules consisted of neuroglia cells and 
fibres in various stages of growth ; a few contained indications 
of former haemorrhages in the presence of haematoidin crystals. 
The few nerve cells present were very irregular in arrangement, 
as well as being atrophied and distorted. The lamination of the 
adjacent cortex also was much disturbed, and there were many 
nerve cells in a condition of imperfect development, as well as 
others undergoing chronic pigmentary atrophy. Other portions 
of the cortex which were not occupied by nodules were sur- 
mounted by a definite band of sclerotic tissue, this being situated 
immediately underneath the pia-arachnoid membrane. The 
corpora striata also were studded with protuberances of fine glia 
tissue, ranging in size from a grape-stone to a large pea ; but the 
ventricles were not dilated, and the ependyma was normal. 
Several of the leaflets of the lobus clivi of the cerebellum were 
markedly atrophied, and in these the number of Purkinje's 
cells was much diminished. There was also slight interstitial 
sclerosis of the pyramidal tracts and antero-lateral columns of 
the spinal cord. These lesions of the cerebellum and cord were 
probably secondary to the cortical sclerosis. 

A case presenting identical histological features to the above 
was described by Dr. Joseph Sailer.* In this there was an 

* J. Sailer, " Hypertrophic Nodular Gliosis," American Journal of 
Nervous and Mental Disease, 1898, p. 402. 



Secondary Amentia and its Clinical Varieties 235 

insane and alcoholic heredity, and spasms began at the age of 
ten months. The mental condition was one of low-grade idiocy. 
Epileptic convulsions were frequent, and the patient died, aged 
fifteen, of exhaustion after a succession of fits. 

Another similar case was described by Dr. Margaret B. Dobson.* 
In this there was a marked family history of tuberculosis, alco- 
holism, and epilepsy, and the patient, a male epileptic idiot, died 
at the age of ten years from pneumonia accelerated by exhaus- 
tion from epilepsy. The post-mortem appearances were similar 
to those already described. 

HYDROCEPHALIC AMENTIA. 

Primary amentia may be complicated by hydrocephalus, and 
this condition is even occasionally found in making post-mortem 
examinations of microcephalics. The term " hydrocephalic 
amentia," however, is better restricted to those cases in which 
the mental deficiency is secondary to this lesion. 

As to the cause of hydrocephalus much uncertainty exists. 
Some cases are the after-effect of chronic meningitis or tumours 
(usually syphilitic or tubercular) of the base of the brain ; in 
others no antecedent lesion can be discovered. However pro- 
duced, the essential condition consists of an accumulation of 
cerebro-spinal fluid, which may amount to several pints, within 
the ventricles of the brain. In consequence of the pressure of 
this fluid, the brain tissue adjacent to the ventricles is gradually 
thinned and destroyed. In extreme cases it may be reduced 
to a mere shell but a fraction of an inch in thickness, so that 
the hemispheres resemble a huge cyst. The parts least affected 
are the cerebellum and basal ganglia. 

The expansile force of the fluid is usually marked upon the 
skull, the bones of which become widely separated ; and this, 
with the general enlargement, produces a clinical picture which 
cannot well be mistaken. But in some instances hydrocephalus 
may exist with a small skull, owing to premature ossification of 
the cranial bones, and the condition will then only be revealed 
after death. Such are usually pronounced idiots ; convulsions 
are frequent, and death takes place early. 

* Margaret B. Dobson, " A Case of Epileptic Idiocy," etc., Lancet, 
December 8, 1906. 



236 Mental Deficiency 

Occasionally hydrocephalus exists before birth, but if at all 
severe it is rarely possible for the child to be born alive ; and in 
the majority of cases met with the onset takes place in the first 
few months, or it may be years, of life. There can be no doubt 
that a great proportion of children so affected die within a few 
years. In other cases a spontaneous cure takes place, and it has 
even been affirmed by Edinger that a mild hydrocephalus occur- 
ring in childhood, and not progressing, may actually favour 
mental development by causing a lessened resistance to the 
growth of the brain. In most cases, however, there results some 
degree of mental deficiency. 

The subsequent course differs, and in the main there are two 
types. In one, whilst the patient may be imbecile, or even 
idiotic, the mental condition is of secondary importance, in view 
of the active and steadily progressive nature of the disease to 
which it is due. Such children are acutely ill, the body is 
wasted, convulsions are frequent, and severe paralysis is generally 
present. Many of them are bedridden. They may be blind or 
deaf from the pressure of fluid, and optic atrophy is often seen. 
Although the alienist may be consulted with regard to these 
cases, their place is the hospital ward, and not the special institu- 
tion, and death soon closes the scene. In some instances con- 
siderable amelioration of the mental symptoms takes place 
immediately before death. 

The second type, those cases usually seen in special institu- 
tions, or which come under notice on account of amentia, are 
those in which the hydrocephalus is either increasing very slowly 
or has undergone spontaneous arrest. In these cases the mental 
deficiency varies from a mild degree of feeble-mindedness to pro- 
nounced imbecility, and, as a rule, a moderate amount of improve- 
ment takes place as a result of special training. Dr. Ireland 
quotes the case of a boy under his care who lost his hearing after 
being several years at Larbert, and gradually lost many of the 
words he had learned. " He was taught a number of figurative 
signs, and also to spell on his fingers ; and although he had the 
additional disadvantage of obscurity of sight — having dimness of 
the cornea, resulting from ophthalmia — his progress was as well 
marked as that of any pupil in the establishment." 

The majority of hydrocephalic aments are quiet, confiding, 



Plate XIX. 
SECONDARY AMENTIA DUE TO HYDROCEPHALUS. 





^ 


r 




. 






>- 

*- 


i 




4 

■HI J 


.y" 


^^ N 






HH 


r^i% j . , 


• y 



Fig. 47. — Male hydrocephalic. Age, i| years. 
(From a photograph lent by Dr. J. Thomson!) 

MICROCEPHALIC AMENTIA. 



n 



I * 




Fig. 4S. — Female microcephalic. Age, 4I months. 
(From a photograph lent by Dr. J. Thomson.) 
To face page 236.] 



! 



Secondary Amentia and its Clinical Varieties 237 

affectionate, and obedient, and although paresis may prevent the 
performance of much in the way of manual work, they are usually 
very willing to do what they can. Owing to their muscular 
weakness, movements are clumsy and badly co-ordinated, and in 
some cases severe paralysis may be present. The legs are more 
frequently and more severely involved than the arms. Impair- 
ment of sight and hearing are also common ; strabismus is fre- 
quent ; and in the more severe cases nystagmus occurs. Epileptic 
convulsions are usually present in the acute stage, but tend to 
diminish, and often disappear altogether, in the chronic cases 
seen in institutions. Most patients are undersized, but there 
are no stigmata of degeneracy. (See Plates XVIII. and XIX., 
Figs. 46 and 47.) 

The peculiar enlargement of the skull makes diagnosis easy. 
The hydrocephalic skull is uniformly increased in all directions, 
and thus tends to assume a globular shape. The forehead is high 
and projecting, and there is usually a characteristic bulging at 
the root of the nose, but the greatest circumference is at the level 
of the temples. The fontanelle is tense, and the sutures often 
widely separated. In the arrested cases, however, these become 
filled in with Wormian bones, and the component parts of the 
cranium become firmly united. The scalp is thinned, and often 
marked by large and prominent veins. The excessive size of the 
cranium, in conjunction with the small face, causes the head, as 
seen from the front, to have a very characteristic conformation, 
resembling an inverted pyramid, thereby producing a curiously 
"top-heavy" appearance. The circumference varies from a 
little above the normal to as much as 30 inches or more. The 
average measurement of the chronic cases seen in institutions is 
about 25 or 26 inches, but there is no constant relationship 
between the size of the skull and the degree of mental impair- 
ment. The prognosis will depend upon whether the disease is 
stationary or slowly progressing. In the latter dementia is 
usually the ultimate result. 

The two conditions which might be confounded with hydro- 
cephalus are hypertrophic amentia and rickets. The distinction 
in regard to the former of these has already been given. In 
rickets the skull is often enlarged, but such is due to a thickening 
and increased density, and not a distension. Moreover, the 



238 Mental Deficiency- 

rickety skull is usually asymmetrical, bossed, and ridged ; the 
fontanelle, if still open, is depressed, and not elevated ; there is 
an absence of the thin and prominently veined scalp, and other 
signs of rickets are present 

Illustrative Cases. 

G. P., male, was admitted into the Littleton Home for Defective 
Children when six years of age. He was an orphan, and no 
history bearing upon his condition was obtainable. He was a 
delicate-looking boy of average height, with a typical hydro- 
cephalic skull, the circumference of which was 22J inches. The 
palate was high and saddle-shaped, the teeth irregular. There 
was left internal strabismus, also deficient power, but no definite 
paralysis, of the left arm and leg. He dragged both feet in 
walking, and the body balance was poor. He knew his letters 
and numbers, and could spell a few simple words, and his mental 
condition generally was one of mild defect. Articulation was 
good, and his disposition was bright and cheerful. There was 
very little change for three or four months, although the boy made 
no headway in school. He then began to be silent and pensive, 
and to lose interest in his surroundings. The physical signs also 
increased, the legs became definitely spastic, so that walking 
was impossible, and all movements were performed with diffi- 
culty. By the end of six months the cranium had increased 
} inch in circumference, and, as he was becoming physically 
helpless and showing signs of dementia, I was compelled to 
discharge him. 

C. H., male. The fifth born of a family of eight, two of whom 
are said to be in good health, although one is a heavy drinker. A 
third is " very delicate," and the remainder died in infancy ; 
one was a cripple. The father died, aged fifty-two, of bron- 
chitis ; the mother died, aged forty-seven, of general paralysis. 
The patient seemed all right at birth, but had a " fit " when a 
year old, and from that time his head was noticed to get rapidly 
bigger. He did not walk until late, and then very badly, and he 
always seemed more simple and childish than other children. 
He made little progress at school, and at the age of fourteen was 
admitted to an imbecile institution. He remained there for two 
years, but, becoming destructive and violent, he was transferred 



Secondary Amentia and its Clinical Varieties 239 

to an asylum. He was a pronounced hydrocephalic, in poor 
physical condition, but clean in his habits ; able to converse, and 
capable of helping a little in the wards. The head increased in 
size, and he gradually became more helpless. He is now eighteen 
years of age, and has been bedridden for over a year. His con- 
dition is as follows : The skull is typically hydrocephalic, and 
measures 25 inches in circumference. There is spastic paresis 
of both legs from the thighs downwards ; he can just stand, but 
is quite unable to walk. The arms do not appear to be affected. 
The knee-jerks are increased, and double ankle clonus is present ; 
also Babinsky's toe sign. On making movements a marked 
clonus of the legs appears, but there are no convulsions. He can 
hear and see, but is of decidedly defective understanding. As a 
rule, when questioned, he gazes at one in a stolid, helpless way, 
and makes no attempt to reply ; when he does speak, his words 
are unintelligible. He pulls to pieces everything which comes 
into his hands, but takes practically no notice of persons or things 
round him. It is obvious that the disease is rapidly progressing. 

/. T., male. The fourth of a family of five, of whom one died 
in infancy ; the others are alive and well. There is insanity on 
the father's side, and consumption on the mother's. The 
patient was born with a very big head, labour being much 
prolonged. He did not walk until turned four years, and has 
always been clumsy in his movements. He was a little back- 
ward at school, but no marked mental abnormality was noticed 
until the age of ten, when be began to get passionate and difficult 
to control. He showed a remarkable memory for ages, and his 
mother says that he knew the age of every one of their numerous 
relations. 

He left school aged fourteen, and was put to bootmaking ; but 
he never did much good, and after a short time he was taken 
away. He remained at home pottering about, but doing no 
work, until thirty-four years of age. A change then came over 
him ; he began to wander about at night, and sometimes stayed 
away from home for several days together. He would put 
tobacco into the teapot, and do similar foolish things. He 
became rambling in his conversation, and said that " Jack the 
Ripper " had tried to cut his throat. He refused his food, 
saying that it had been drugged. Finally he attacked his 



240 Mental Deficiency 

mother with a knife, and became so maniacal that he had to be 
sent to an asylum. 

On admission he had a typical hydrocephalic head, convergent 
strabismus, and slight dragging of the left leg. He was loquacious, 
but of decidedly feeble intellect. The maniacal condition passed 
off, and he became quiet and well-behaved, and he remained in 
this condition for several years, subject, however, to delusions 
that some unknown persons put poison into his food. Then the 
legs became weaker, so that he was unable to get about, and 
now, at the age of forty-five years, he is bedridden. There is 
well-marked spastic paraplegia, so that he is unable to walk, or 
even stand, without support. The arms are unaffected. The 
knee-jerks are increased, and Babinsky's sign is present on the 
right side. Both legs and feet are blue and cold. There is no 
diminution in tactile sensation over any part of the body, and 
his power of localizing touch is remarkably good. He frequently 
complains of a girdle sensation round the epigastrium. There is 
fine tremor of the hands on extension, and of the legs on attempt- 
ing movement, but no convulsions of any kind. The special 
senses are normal. Articulation is slightly defective, but speech 
is coherent and rational. Memory is very good indeed. He 
notices all that goes on round him, and can give a very good 
account of his past life, but his ideas are childish and his judg- 
ment and reasoning defective. He can read, write, and do sums 
remarkably well. He has lately developed incontinence. The 
cranial circumference is 25 J inches. 



SYPHILITIC AMENTIA. 

It is a somewhat remarkable fact that, although syphilis is a 
frequent cause of disease in the fully developed brain, and 
although so-called inherited (really acquired in utero) syphilis 
is exceedingly common, yet the number of cases of amentia due 
to this cause is quite insignificant. They probably do not com- 
prise at most more than 1 or 2 per cent, of all aments. One is 
driven to the conclusion that syphilis is a much more potent 
agent in producing neuronic degeneration than arrest, and this 
view is confirmed by the subsequent history of many aments 
who owe their deficiency to this cause. Further, in most of 



Secondary Amentia and its Clinical Varieties 241 

these cases in which syphilis is a factor there are other influences, 
generally neuropathic heredity, and it would seem as if the 
specific virus were chiefly productive of harm upon the nervous 
system in the presence of a neuropathic or psychopathic diathesis. 
In my own series of cases the number of aments whose condition 
was the result of syphilis alone (without neuropathic heredity) 
was but 0'5 per cent. It is interesting to note that the same 
applies also to degenerations of the brain and spinal cord 
occurring in later life. General paralysis, of which syphilis is 
the predominant exciting cause, has been shown to be accom-^ 
panied by morbid neuropathic heredity in a large proportion of 
cases ; and Mott has shown that the site of incidence of the poison 
upon the spinal cord is often determined by antecedent localized 
stress and strain producing a locus minoris resistentice. 

There are several ways in which the poison of syphilis may con- 
ceivably determine amentia — one, by producing such a general 
disturbance of nutrition as to arrest neuronic growth, this I 
believe to be exceedingly rare ; another, and in my opinion the 
usual modus operandi, by directly poisoning and so checking 
the growth of the developing cortical cells. It has been stated 
by some writers that syphilis can only produce amentia by 
causing gross lesions of the skull, membranes, or brain. Possibly 
some cases of hydrocephalic amentia are of this nature, but I 
do not think that this result is common. It is true that in a 
considerable proportion of cases the defective neurones subse- 
quently undergo degeneration, and that considerable wasting of 
the brain ensues ; but even this is not accompanied by the 
ordinary syphilitic lesions, and I think that in most cases 
amentia, in the first instance, results from the growth of the 
neurones being interfered with by a syphilitic toxaemia. 

In addition to this, syphilis may, of course, produce amentia 
indirectly by bringing about a devitalization of the germ plasm, 
as we have already mentioned in treating of causation. But 
such cases hardly come within the category of syphilitic amentia, 
for this action of the poison is hereditary, and such cases are 
primary, not secondary amentia. The specific signs of syphilis 
are absent, and the condition is in reality what has been described 
by Fournier as " parasyphilitis' 

In cases of secondary amentia directly due to, or determined 

16 



242 Mental Deficiency 

by, syphilis, which are the only ones to which we shall apply 
the term "syphilitic amentia," the usual symptoms of inherited 
syphilis are present in infancy, and their characteristic lesions — 
— viz., keratitis, Hutchinson's teeth, scars, depressed nose, etc. — 
are generally found in after-life. In addition, the body is usually 
stunted and ill-formed, the child is backward in walking and 
talking (one of my cases did not speak at all until the ninth year), 
and some amount of mental deficiency is usually apparent in the 
first few years of life. As a rule, this is of a comparatively mild 
degree, most of the cases being merely feeble-minded or high- 
grade imbeciles. They go to school, but make no progress, and 
upon leaving they are found incapable of following any constant 
employment. Occasionally the mental status is that of idiocy ; 
but up to the age of twelve to fifteen years the syphilitic ament, 
beyond the presence of the typical lesions, presents no special 
mental peculiarities which distinguish him from an ordinary 
ament of similar degree. 

About or shortly after the usual age of puberty, however, a 
considerable number of these persons undergo a remarkable 
change. It is noticed that the patient is becoming restless and 
troublesome. Hallucinations and delusions often make their 
appearance, and in some cases there is pronounced mania or 
melancholia. Soon after this the balance and gait of the body 
become markedly unsteady, there is considerable tremor of the 
hands, mouth, and tongue, and the speech becomes slurred, in- 
distinct, and hesitating. The knee-jerks are increased, and ankle 
clonus is often found. Sight and hearing are impaired, and if 
the eyes be examined the pupils will be seen to be dilated and 
to react sluggishly to light ; at a later stage they become fixed. 
These changes are followed by a marked mental impairment, 
and the youth ceases to take any interest in his surroundings. 
There is no remission, and time only results in an aggravation 
of all these symptoms. The body begins to waste, swallowing 
becomes difficult, and the patient gets dirty in his habits. With 
the emaciation there is often considerable trophic disturbance, 
so that sores appear. Finally he becomes bedridden, gradually 
sinks into a comatose state, and dies. In males the external 
genitals retain their infantile condition, and in females men- 
struation does not appear. I have never noticed any grandiose 



Secondary Amentia and its Clinical Varieties 243 

ideas in these persons ; but convulsive seizures are common, and 
these are occasionally followed by transient paralysis. The 
average length of time from the onset of these symptoms to the 
end is about five years. 

It is seen that the symptoms and course of this progressive 
degeneration are practically identical with those of juvenile 
general paralysis, and this is further shown by the post-mortem 
appearances. In four cases which I have examined post-mortem 
the brain was small and simply convoluted as well as wasted, 
the pia-arachnoid thickened and opaque, and the cerebro-spinal 
fluid in considerable excess. There were, however, no gross 
syphilitic lesions. Microscopical examination showed many cells 
in a typical condition of incomplete development, but over and 
beyond this there were extensive degenerative changes indis- 
tinguishable from those occurring in general paralysis.* 

I do not think that this is the termination of every case of 
syphilitic amentia, for I have seen a few of these patients who, 
at over thirty years of age, showed no mental or physical altera- 
tion apart from the original deficiency. But although I have 
made diligent search, these latter cases are comparatively rare, 
and I am inclined to think that progressive deterioration, ending 
in paralytic dementia, is the rule in amentia due to syphilis. 

The Diagnosis of syphilitic amentia rests upon the presence of 
the typical lesions, plus amentia, in the patient. In one of my 
cases the signs were indefinite, but the patient's mother had died 
of general paralysis. In another case a history was present, but 
no marks could be discovered upon the patient ; a brother, how- 
ever, presented the characteristic signs. Both these cases were con- 
sidered to be probably syphilitic, and they subsequently developed 
general paralysis. Diagnosis at times, therefore, must be a 
matter of uncertainty. The remaining cases showed the charac- 
teristic lesions. It need hardly be emphasized that all subjects of 
congenital syphilis do not suffer from mental deficiency ; on the 
contrary, the proportion who become aments is exceedingly 
small. It is probable that in most of these cases the arrest 

* For one of the best accounts of the histology of juvenile general 
paralysis, as shown by modern methods of staining, see that by Watson 
in Mott's " Archives of Neurology," vol. ii., p. 621. Three, at least, of 
the twelve cases there recorded were aments. 

l6 — 2 



244 Mental Deficiency 

of mental development is as much a consequence of morbid 
heredity as of the syphilitic virus, since such heredity, or some 
potent predisposing cause, is present in the majority of cases. 
Given a child with congenital syphilis, who is at the same time 
the offspring of a neuropathic or degenerate stock, then I think 
that amentia is extremely likely to result. 

It has been stated by Hirsch that all individuals suffering from 
juvenile general paralysis have previously been of feeble intellect. 
With this, however, I cannot agree, as I have known several such 
patients whose mental condition had been quite up to the normal 
prior to the onset of the degenerative changes. But juvenile 
general paralytics who are seen in the consulting-room or asylum 
in the early stages of their disease are often thought to be 
imbeciles. Inquiries as to the previous mental status will readily 
distinguish between the two conditions. 

Prognosis. — In view of the liability of these patients to develop 
general paralysis, it is obvious that a most guarded opinion must 
be given regarding the ultimate prospects of improvement from 
training, in any case of amentia which is considered to be syphi- 
litic. Progressive dementia does not always result, but it does 
certainly appear to be extremely common ; and antisyphilitic 
treatment has been found to have not the slightest effect upon 
either the degeneration or the initial mental deficiency. 

Illustrative Cases. 

Syphilitic Amentia terminating in General Paralysis. — M. D., 
female, the sixth of a family of ten. The fifth died of " water 
on the brain " in infancy, and the seventh and eighth were mis- 
carriages. The remainder are said to be " all right." There is 
phthisis on the mother's side, but no insanity discoverable. The 
patient was decidedly backward at school ; afterwards she 
stayed at home to help her mother, as she did not seem equal to 
taking a place. At the age of nineteen years she began to get 
mischievous and destructive, and finally became so troublesome 
that she had to be sent to an asylum. On admission in 
October, 1899, she was described as being of very poor intelli- 
gence, wet and dirty in habits, noisy day and night, talking 
incessantly and using disgusting language without any con- 
nexion of ideas. Her condition was such that systematic 



Secondary Amentia and its Clinical Varieties 245 

examination was impossible. She gradually became somewhat 
quieter, and when seen by me, nine months after admission, her 
condition was as follows : A lethargic, almost stuporose, girl who 
spent the whole day sitting in a chair, indifferent to anything 
happening round her. She understood what was said to her, but 
was unable to carry on conversation or to answer simple questions 
properly. Speech slurred and tremulous. She attempted to 
write at my request, but her hand was so tremulous that it was 
impossible to do so. Knee-jerks greatly exaggerated ; ex- 
tremities blue and cold. No paresis ; no seizures. Well-marked 
signs of rickets and congenital syphilis. I diagnosed syphilitic 
amentia, with beginning general paralysis, but was unable to 
see the patient again, and had forgotten entirely about her until 
going through my notes. The medical superintendent was good 
enough to supply me with the subsequent history, from which 
it appeared that unmistakable signs of general paralysis appeared 
towards the end of 1901 ; that phthisis was observed in February, 
1902 ; and that she died on March 29 of the same year. Her 
age at death was twenty-three years, and the cause, as ascer- 
tained post-mortem, was general paralysis and phthisis. 

Syphilitic Amentia terminating in General Paralysis. — 
T. C, male. Father alcoholic and insane ; his mother and all 
his brothers and sisters alcoholic. The patient is the second of a 
family of eight ; the first-born died aged two and a half months, 
and the mother was told by the doctor that, had it lived, " it 
would have been blind and an idiot." The fourth child, whom 
I have seen, has marks of congenital syphilis. The patient was 
backward in walking and talking ; his mother says he could 
never " get his words out properly." He went to school, but 
could never learn, and the schoolmaster said he was " a regular 
fool." He subsequently had several situations, but no one would 
keep him very long. At fifteen years of age he began to get very 
bad-tempered and strange in his manner ; he had attacks of 
screaming, which lasted for hours ; and ultimately, at seventeen 
years, was sent to an asylum with acute mania. This gradually 
subsided, revealing a condition of mild imbecility with beginning 
dementia. When asked his name and age, he would plaintively 
reply: "I ain't got no name" and "I ain't got no age." The 
dementia progressed and became extreme, and he died, aged 
nineteen, of exhaustion following a bout of seizures. 



246 Mental Deficiency 

The post-mortem examination revealed a simply convoluted 
brain, weighing 1,167 grammes, and having the characteristic 
appearances of general paralysis. The microscope showed a 
condition of imperfect cellular development, plus subacute 
degeneration, similar to that occurring in general paralysis. 

Syphilitic Amentia passing into Dementia {probably General 
Paralysis). — A. A., male. Morbid heredity on paternal side, 
but no history of syphilis obtainable, although the patient has 
several characteristic syphilitic lesions. He was noticed to be 
backward from birth, and did not talk until eight years old. 
Went to school, but could never learn, and when he left, at the 
age of twelve, he was only in the second standard. He had fits 
between six and seven years of age, which continued occasionally 
until fourteen years, and then ceased. No employment. Became 
unmanageable, and was sent to an imbecile institution when aged 
seventeen. Remained there for two years, but made no progress, 
and was transferred to an asylum. He gradually became paretic 
and tremulous, with small pupils, which scarcely reacted to light. 
At the present time (aged twenty) he is very simple, and answers 
questions in a slow, monotonous, and trembling manner. He 
cannot do the simplest sums, and does not know how many 
pennies there are in sixpence. There is undoubtedly con- 
siderable mental deterioration in addition to the original defect, 
and it is probable that general paralysis is supervening. 

Syphilitic Amentia terminating in General Paralysis. — L. B., 
female. Was admitted into the asylum at the age of fifteen, the 
certificate stating : " She sits apparently dazed, taking no interest 
in anything that is going on. Threatened to kill herself. Tears 
her clothing, and at times cries and stamps her feet." The history 
is incomplete, but it was elicited that the patient had been dull 
and of defective eyesight since birth ; that her mother died, aged 
forty-two, of general paralysis ; and that her father was alive, 
and said to be in good health. Though intellectually dull, she 
was said to have been cheerful until the last six months, since 
when she had become stubborn and morose, finally helpless, 
dirty in her habits, and quite unable to look after herself. 

On admission the pupils were dilated, the reaction to light 
sluggish, and her memory for time and events much impaired. 
She was gloomy and apathetic, and had delusions, such as that 
ferocious dogs were coming after her. There was left external 



Plate XX. 







3^ 




f" /!» •'! 


ki' 


It 


LU " > 


■ 








. 




To face page 246.] 



Secondary Amentia and its Clinical Varieties 247 

strabismus, but no other observable paresis and no convulsions. 
The knee-jerks were exaggerated. Marks of congenital syphilis 
were present. Cranial circumference, 21J inches. She was con- 
sidered to be a case of syphilitic amentia with superadded dementia. 
The dementia steadily increased, and the patient died at the age 
of eighteen years, of broncho-pneumonia. 

On making a post-mortem examination, I found the brain to 
be of fair size (1,176 grammes), but somewhat simply convoluted. 
The optic nerves were exceedingly small. The brain and mem- 
branes had the characteristic naked-eye appearances of general 
paralysis. A microscopical examination of various regions of the 
cortex cerebri revealed a marked numerical deficiency of the cells ; 
many of them were also of incomplete development and irregular 
arrangement. These indications of imperfect development were 
most pronounced in the small and medium-sized pyramidal cells 
of the frontal lobes. In addition, there was a considerable 
amount of chronic and subacute degeneration, with proliferation 
of neuroglia identical with that occurring in general paralysis. 

Syphilitic Amentia with Progressive Dementia. — 5. G., male. 
No relatives living, and no history or particulars ascertainable 
beyond the fact that he had lived in imbecile institutions since 
the age of nine years. In January, 1895, at the age of nineteen 
years, he became violent and unmanageable, attacked the atten- 
dants, and threatened to cut his throat ; he was accordingly 
transferred to a lunatic asylum. On admission he was found 
to be an imbecile with aural hallucinations and mild mania. He 
said that voices spoke to him and told him to cut his throat. 
Many typical marks of congenital syphilis were present, and he 
had a habit of constantly keeping his mouth tightly closed 
in a fatuous grin, at the same time breathing noisily through 
his nose. (See Plate XX., Fig. 49.) He remained in practi- 
cally the same condition for the next five years, at times 
being depressed and lachrymose, at others noisy and trouble- 
some; he was, however, clean in habits, and was capable of 
doing everything for himself. In December, 1900, at the age 
of twenty-four years, he began to show signs of dementia, 
becoming stolid and indifferent to his surroundings, and fre- 
quently wet and dirty. The knee-j erks were greatly exaggerated. 
The dementia gradually became more marked, his gait became 
shuffling and unsteady, and the knee-jerks could not be obtained. 



248 Mental Deficiency 

During the year 1902 he began to show marked bodily enfeeble- 
ment, the dementia still continuing to progress. In February, 
1904, pulmonary tuberculosis was diagnosed ; it advanced with 
great rapidity, and he died the following month at the age of 
twenty-eight years. There had never been convulsions or 
seizures. Post-mortem examination revealed a wasted brain 
presenting the usual features of chronic dementia, but none of 
the particular signs of general paralysis. Its weight was 1,100 
grammes. There was extensive tuberculosis of both lungs. 

Syphilitic Amentia passing into Dementia* — Family History. — 
The father has had syphilis ; a brother of the patient also has 
" tremblings " ; no further details obtainable. 

Clinical.— The patient was always a quiet lad, and did not 
seem so bright as the other children. At the age of six years he 
began to show definite ataxic symptoms (said to have been 
caused by a fright), chiefly marked in the legs. There was no 
actual loss of power complained of, but he was only able to 
stand with the feet apart, and was very unsteady and apt to fall 
whilst walking ; the knee-jerks were absent on both sides, the 
pupils were widely dilated, considerable tremor of the eyelids was 
present, and there was occasional incontinence of urine. The 
patient gradually became worse, eventually becoming almost 
completely powerless and helpless in bed, and quite demented : 
he died at the age of eight years. 

Upon making a microscopical examination, I found imperfect 
development and irregular arrangement of the small and medium- 
sized pyramidal cells of the cerebral cortex, indicating a condition 
of mild imbecility. In addition there was a subacute degenera- 
tion affecting a large number of these cells, and to a less extent 
those of the anterior horns of the spinal cord ; there was also a 
somewhat more chronic degeneration of the cells and fibres of the 
pyramidal tract, and the vessel walls generally were slightly thick- 
ened. I did not see this case during life, but there are many 
points in both the clinical and pathological appearances which 
suggest that this degenerative process which was superadded to 
the mild amentia was analogous to, if not identical with, that of 
juvenile general paralysis. 

* For the clinical notes and the central nervous system of this case 
I am indebted to Dr. F. J. Smith, Physician to the London Hospital. 



Secondary Amentia and its Clinical Varieties 249 



AMAUROTIC FAMILY IDIOCY, OR INFANTILE CEREBRAL 
DEGENERATION. 

This disease is invariably fatal, and its subjects never survive 
sufficiently long to become candidates for a special institution for 
the mentally deficient ; but as it is one in which arrested cerebral 
development is a prominent, although incidental, feature, and as 
on this account it might be confounded with the more ordinary 
forms of amentia, it is necessary to allude to it. 

The earliest account we have is that given by Mr. Waren Tay 
in 1881, whose description chiefly referred to the peculiar ocular 
conditions. In 1887 Dr. B. Sachs, of New York, described the 
changes in the brain in a paper entitled " Arrested Cerebral De- 
velopment." Other descriptions have been given by Goldzicher, 
Magnus, Knapp, Wads worth, Hirschberg, Carter, Hirsch, Petersen, 
and Burnet. The most complete account, however, is that of 
Kingdon and Risien Russell,* which appeared in 1897, and it is 
upon this that the description here given is chiefly based. 

Infantile cerebral degeneration is a disease which usually 
attacks more than one child of the same family, and all the cases 
hitherto recorded have occurred in Jews. Male and female chil- 
dren are equally liable to be affected, but no particular exciting 
or predisposing factor has yet been discovered. There is no 
regularity in the order in which children of the same family are 
affected. It may be the earlier, later, or intermediate children, 
the rest remaining perfectly healthy. Kingdon and Russell 
describe the symptoms and progress of the disease in three stages 
as follows : 

First Stage. — An infant, the subject of this disease, is born at 
the full time of gestation, and may be well formed and developed, 
differing in no outward respect from a healthy child, until about 
the completion of the third month. At this time some weakness 
of the muscles of the back and neck is observed, and often a sus- 
picion that the child sees imperfectly is entertained. Should the 
eyes be examined with the ophthalmoscope about the fourth or 

* E. C. Kingdon and J. S. Risien Russell, " Infantile Cerebral Degenera- 
tion," Medico-Chirurgical Transactions, vol. lxxx., 1897. This paper 
gives a full account of the clinical and pathological conditions, together 
with a bibliography of the subject. 



250 Mental Deficiency 

fifth month, there will be found symmetrical changes in the macula 
lutea, consisting of a whitish-grey patch, somewhat oval in shape 
(the axis being horizontal), with softened edges slightly raised 
above the general surface of the retina. In the centre of this 
patch is seen the fovea centralis as a dark cherry-red spot. These 
changes in the maculae remain unaltered, and are regarded as 
absolutely pathognomonic. At a somewhat later course of the 
disease there is definite optic atrophy and total amaurosis. 

In the Second Stage the child is unable to sit up ; its head 
falls backwards if unsupported ; when lying on its back it is un- 
able to turn over to either side. Objects placed in its hands are 
grasped but feebly, and soon dropped. It is generally apathetic, 
taking no notice of surrounding objects, and the face bears an 
expression of mental enfeeblement. Vision is reduced to per- 
ception of light, but the sense of hearing is acute, and remains so 
during life, any sudden sound causing the child to start. The 
sense of taste is also preserved. 

In the Third Stage atrophy of the enfeebled muscles ensues, 
and soon those of the whole body are involved. Emaciation pro- 
gresses, and becomes most marked. The deep reflexes are exag- 
gerated, and still later in the course of the disease rigidity of the 
extremities and retraction of the head become prominent 
features ; occasional spasmodic contractions cause the child to 
start and cry from pain. Convulsions have been noted in one or 
two instances during the course of the disease, but they would 
appear to be an accidental accompaniment, and are, at all events, 
not the rule. The temperature remains normal throughout the 
course of the disease. The heart, lungs, and abdominal viscera 
are also normal. 

The duration of life varies from one and a half to two and a 
half years, but is usually less than two years. All the subjects of 
this disease are known to have died except two, and they were 
becoming worse when last seen. 

The essential pathological lesion would appear to be a primary 
degeneration of the cortical neurones, the optic nerves, and the 
pyramidal tracts throughout their whole course in the pons, 
medulla, and spinal cord. The nature of the lesions and the 
general clinical course would suggest that the cause is some circu- 
lating toxine, but hitherto none such has been discovered. 



Secondary Amentia and its Clinical Varieties 251 

Section II. 

AMENTIA DUE TO DEFECTIVE CEREBRAL NUTRITION. 

Mental growth takes place as a result of two factors. First, 
the embryonic neuroblasts must have within them a capacity for 
developing and acquiring certain functional connexions. Secondly, 
they must be supplied with food adequate in quantity and quality, 
and they must also be stimulated by impressions from without 
reaching them through the avenues of special sense. If either of 
these latter essentials to growth be absent or diminished, mental 
development may be so interfered with that a condition of 
amentia results, and this is conveniently termed " amentia due 
to defective cerebral nutrition." Of the type which is due to 
quantitative or qualitative changes in the blood, cretinism is the 
best, as well as most common, example. The variety due to 
defective stimulation is known as " amentia due to isolation or 
sense deprivation." 

CRETINISM. 

Although cretins have been recognized and remarked upon for 
hundreds of years (even by such ancient writers as Juvenal, Pliny, 
Strabo, as well as by the more modern Paracelsus), it is only 
comparatively recently that the cause of this condition has been 
at all understood. It is now established beyond doubt that 
cretinism is closely allied to myxcedema, and that they are both 
dependent upon an absence or diminished secretion of the thyroid 
gland. 

There are two kinds of cretinism — endemic and sporadic ; and 
although these have much in common, there are, nevertheless, 
important points of difference between them which make it 
necessary to consider them separately. 

Endemic Cretinism. — Endemic cretinism is a disease of wide 
incidence. It is most common in Europe, particularly in the 
mountains and valleys of Switzerland and the adjacent countries ; 
but it also occurs in the Himalayas of India, the Andes and 
Rocky Mountains of America, as well as in Burmah and Mada- 
gascar. In fact, there is hardly any quarter of the globe which 



252 Mental Deficiency 

is free from this affection. In England cases are occasionally 
seen in Derb} r shire and the western portion of Yorkshire. In 
Somersetshire it used to be fairly common, but is not now so 
frequently seen. In practically all cases of the endemic form of 
this disease a goitre is present, but although some diversity exists 
in the mental and bodily condition of the patients, the effect on 
the whole seems to be the result of an inadequate and not exces- 
sive secretion of the thyroid gland. 

As to the cause of this thyroid anomaly we know very little, 
but it seems to be related in some peculiar manner with the 
water-supply. It is probable that the future will reveal the 
presence of some specific microbe or virus, but hitherto none has 
been isolated. 

In consequence of this condition of the thyroid a marked 
alteration takes place in the bodily and (usually) mental state 
of the person affected. In congenital or infantile cases the whole 
nutrition of the body is disturbed. The child, whilst usually 
remaining fat and puffy, makes very little growth, and the 
majority of these persons remain dwarfs. The skin is sallow or 
actually yellow, dry, thickened, and wrinkled, and has the 
appearance of being too large for the body. The head is large 
and the fontanelles are late in closing. The. nose is broad and 
flat, the lips thick and swollen, and the tongue so large that it 
often hangs out of the open mouth. The belly is protuberant, 
and the lower limbs short and bowed. The whole body is un- 
wieldy, its balance unsteady, and its gait ungainly. Puberty is 
often delayed, and many pronounced cretins are sterile. In fact, 
these children as a whole present bodily signs identical with those 
of the sporadic variety. In those cases in which the disease is 
acquired in later life, as a consequence of residence in a goitrous 
locality, changes analogous to those occurring in myxcedema are 
produced. 

It has been stated that this condition of athyroidea may exist 
without any mental change, and although this may sometimes 
be true where the disease is acquired in later life, and also in very 
exceptional instances in the congenital form, there is usually 
produced some degree of mental deficiency. This ranges from 
a mild amount of feeble-mindedness to a state of gross idiocy, 
and is usually accompanied by deafness. The report of the 



Secondary Amentia and its Clinical Varieties 253 

Royal Commission of Sardinia* divides cretins into the following 
three classes : 

In Class I. the subjects have only vegetative faculties, are 
entirely destitute of reproductive and intellectual powers, and 
cannot speak. They are styled simply " cretins." 

In Class II. they have vegetative and reproductive faculties 
and some rudiments of language. Their intellectual efforts go 
no farther than their bodily wants, corresponding only to the 
impression of the senses. They are called " semi-cretins." 

In Class III. there is added to the faculty of the preceding one 
a greater amount of intellectual power without reaching the 
normal human capacity. They have some aptitude at learning 
a trade or doing different kinds of work. They are called 
"cretineux," or "cretinous." 

Sporadic Cretinism (Cretinoid, Myxoedematous, or Pachydermia 
Amentia). — This condition was first described by the late Dr. 
Hilton Fagge in 1871, and although since then a considerable 
number of cases have been reported, it is nevertheless a rare 
disease. Cretinoid aments do not compose more than a fraction 
per cent, of all aments. 

Although sporadic have many features in common with 
endemic cretins, and although in each there is a condition of 
athyroidea, there are several important points of difference 
between the two. In the first place, whilst a goitre is generally 
present in the endemic form, in the sporadic cases the thyroid 
gland is usually entirely absent. Secondly, although the sporadic 
cases may occur in regions in which goitre is prevalent, they often 
crop up quite apart from such a condition, and in families and 
localities in which goitre is unknown. 

Etiology. — This raises the questions of the cause of sporadic 
cretinism and its relation to the endemic form. In a few of the 
cases coming under my own observation I found a marked history 
of morbid neuropathic heredity, just the same as in ordinary 
primary aments, and this led me to make further inquiries as so 
the prevalence of heredity in this condition. Several consulting 
physicians, having a considerable experience of cretins, and who 

* For these extracts, as well as much information on the subject of 
endemic cretinism, I am indebted to the excellent account in Dr. Ireland's 
work. 



254 Mental Deficiency 

were good enough to reply to my inquiries, informed me that no 
special neuropathic heredity had been noticed ; but they added 
that the majority of the patients had been seen in hospital 
practice, and no special attention had been given to the family 
history. Dr. John Thomson of Edinburgh, however, had fully 
investigated the family history in seventeen of his patients, with 
the following result : In nine there was no history of nervous or 
mental disease or of alcoholism ; of the remaining eight, in one a 
brother and sister were dwarfs, in four there was a family history 
of mental alienation, and in another of epilepsy, whilst the fathers 
of the remaining two patients were alcoholic. 

I am greatly indebted to Dr. Thomson for his kindness in 
supplying me with these details, which seem to show that, 
although on the whole neuropathic heredity is not a marked 
feature of this condition, such nevertheless occurs in a propor- 
tion of cases — that it is, in fact, more prevalent in cretins than 
in ordinary persons. Whether in such cases the absence of the 
thyroid gland should be looked upon as a peculiar stigma of 
degeneracy complicating primary amentia, or whether it is that 
in these cases the athyroidea is due to the same unknown cause 
as in the non-hereditary cases, I am unable to say. The cause 
of sporadic cretinism is shrouded in so much mystery as to be 
at present a complete enigma, and it may be a mere chance that 
the neuropath as well as the non-neuropath should be affected. 
However this may be, it is possible that the presence of morbid 
heredity may be not without influence in affecting the response 
to thyroid treatment, which, although in many cases seemingly 
dependent upon the age at which it is begun, is not entirely 
determined thereby. 

Pathology. — Whatever may be the cause of the thyroid 
anomaly, there is not the slightest doubt that the secretion of 
this gland exercises a profound influence upon the nutrition of 
the brain, and in most, if not all, cases of cretinism it is clearly 
to the absence of this secretion that the mental peculiarity is due. 
It is of interest in this connexion to recall the state of mental 
hebetude, in some cases amounting to dementia, which results in 
the analogous condition of myxcedema seen in adults. 

The defect of this secretion does not lead to any characteristic 
lesion of the brain. The neurones are simply unable to develop 



Plate XXI, 





To face page 254.] 



Secondary Amentia and its Clinical Varieties 255 

and to perform their function because an essential constituent of 
their nutriment is lacking. In several cases which have been 
examined after death, the cortical cells have been found in a con- 
dition of incomplete development, like that already described 
as occurring in primary amentia. Sometimes, in addition, the 
whole brain is found to be small and simply convoluted. 

Clinical Symptoms. — The symptoms of sporadic cretinism 
usually make their appearance during the first year, although 
they are rarely noticeable until the sixth or seventh month. 
Exceptionally they may not occur until the second or third, or 
even sixth or seventh year, but such cases are rare. The parents' 
attention is generally first attracted by the fact that the child 
neither grows so rapidly nor appears as bright mentally as a 
normal child of corresponding age ; also, in the cases with early 
onset, that he makes no attempt to sit up, to stand, or to talk. 
It is commonly said that the primary dentition is considerably 
delayed, but Dr. Thomson doubts this, and he has been good 
enough to supply me with details of ten patients regarding this 
point, from which it appears that, in the absence of rickets, the 
time of dentition does not differ markedly from that of ordinary 
children. The anterior fontanelle is late in closing, and has been 
observed open in adults. Attempts at walking may not be per- 
formed until the fifth year or later. Speech may be delayed until 
the seventh or eighth year, and may never appear. Usually 
within a few years after birth the child has assumed the charac- 
teristic cretinous appearance. 

The characteristic features of the fully developed condition are 
as follows : The body is greatly dwarfed, and many children of 
fifteen or sixteen years of age do not measure more than 
3 feet in height. (The accompanying illustrations (Plate XXL, 
Figs. 51 and 52) show a cretin, aged thirty-nine, whose height is 
only a little over 3 feet). The head is usually large; the legs 
are extremely short and bowed; the hands and feet stumpy 
and ill-formed. The ossification of the bones is delayed con- 
siderably beyond the normal period. The appearance of 
the face alone is often typical, the nose being broad and 
flattened, the eyes widely separated, the lips thick, the mouth 
partly open, and the tongue thick, coarse and protruding. In 
addition, the eyelids are often heavy and swollen, and the hair 



256 Mental Deficiency 

coarse and scanty. A very important feature is the skin, which 
is sallow, exceedingly dry, rough, and so redundant as to appear 
much too large for the stunted body. Doubtless this is the 
result of the under-development chiefly affecting the tissues of 
mesoblastic origin. The neck is usually short and thick and the 
belly protuberant. Umbilical hernia is common. 

Puberty is usually late in appearing, and the external genitals 
often retain an infantile appearance until past mature age. 
Many of these patients are sterile. In the majority of cases the 
thyroid gland is completely absent, and in a considerable number 
of cases there are small soft swellings above the clavicles or in 
the axillae. These are apparently fatty, and they disappear 
rapidly under thyroid treatment. The pulse and respiration are 
slow, and the temperature two or three degrees below the normal. 
As a result of his examination of the blood, Vaquez found that 
there was a marked diminution in the number of the red cor- 
puscles, as well as their contained haemoglobin, with an excessive 
number of nucleated corpuscles. 

These children are often voracious eaters, but, although well 
nourished and even fat, most of them suffer from a general mus- 
cular weakness. This, together with their mental torpidity, 
causes the bodily balance to be unsteady, the gait slow and 
waddling, and all movements to be performed with a laboured 
clumsiness. These bodily peculiarities, associated as they are 
with their general slothfulness, apathy, and want of expression, 
produce a clinical picture which can rarely be mistaken. 

Mentally these persons are characterized by a general im- 
pairment of all the faculties. There is often considerable defect 
in the power of hearing, but beyond an obtuseness of percep- 
tion there is not any other marked abnormality of the special 
senses. Some of them are pronounced imbeciles, or even idiots, 
but in others the degree of mental deficiency is one of mild im- 
becility. Most of these milder cases can be taught to read and 
write simple words, to count, to do little sums in addition and 
subtraction, and to perform small tasks. Others, whilst capable 
of assisting in the domestic work of the institution, make abso- 
lutely no headway in book learning. Most of them can be taught 
to be methodical and clean in their habits. As a class they are 
placid, harmless, good-tempered, and affectionate ; and although 



Secondary Amentia and its Clinical Varieties 257 

they show little trace of emotion, they are nevertheless capable 
of being pleased and amused in a dull, heavy sort of way. They 
are amongst the least troublesome of all aments. 

I know of no statistics enabling the mortality of these persons 
to be compared with that of ordinary aments, but my impression 
is that they are decidedly less frail, and not so prone to early 
death. Phthisis does not seem to be nearly so common. The 
oldest cretin I know is an imbecile man aged sixty- three years. 
He is looked after by his sister, who keeps a small village shop, 
and he is apparently in good bodily health. He has never been 
under thyroid treatment. 

Diagnosis. — In a well-marked case of sporadic cretinism the 
mental and bodily conditions are sufficiently characteristic to 
make the diagnosis easy. But all cases are not equally well 
marked, and there are some other diseases which, owing to certain 
points of resemblance, may be thought to be cretinism. The 
converse mistake, except, perhaps, in the case of rickets, is less 
likely to be made. The chief of these are rickets, hydrocephalus, 
achondroplasia, hypertrophic and Mongolian amentia. 

1. Rickets. — It is not uncommon for early cases of cretinism 
to be called rickets, but the characteristic beading of the ribs and 
symmetrical enlargement of the epiphyses in this latter condition, 
with the absence of the typical cretinous facies, should suffice to 
distinguish between the two. 

2. Hydrocephalus. — The only points in common are the large 
head, the muscular weakness, and the mental apathy. But the 
enlarged head of the hydrocephalic is totally different to that of 
the cretin, and the mental and bodily differences between these 
two conditions are much more pronounced than are the resem- 
blances. 

3. Achondroplasia, although very rare, is often called cretinism. 
It is distinguished by the facts that, although the child is 
dwarfed owing to imperfect development of the long bones, and 
although the skin is often dry and somewhat redundant, there is 
a complete absence of the swollen eyelids, the broad, squat nose, 
the enlarged tongue and mouth of the cretin. Moreover, the 
mental development is unaffected, and children suffering from 
achondroplasia are intelligent and vivacious. 

4. Hypertrophic Aments resemble cretins in the large head and 

17 



258 Mental Deficiency 

somewhat stunted body, and the resemblance may be intensified 
by the tottering gait, general muscular weakness, and mental 
inertia. But the facies of the hypertrophic are different : the 
skin lacks the dryness and redundancy of the cretin, and has not 
the same bogginess ; there is, as a rule, no delay in the develop- 
ment of puberty, and there is not the same, subnormal tempera- 
ture. Moreover, the hypertrophic ament complains of head pain, 
and is often subject to outbreaks of temper and excitement which 
are totally foreign to the lethargic, inert cretin. 

5. Mongolian Aments are frequently thought to be cretins, 
and were for a long time called " cretinoids." The differential 
diagnosis has been given on p. 189. 

Treatment and its Result. — That this condition is the result of 
an absent or defective secretion of the thyroid gland is fully 
shown by the remarkable results which follow thyroid administra- 
tion. Under its influence the characteristic facies disappear, 
the skin becomes moist and supple, the body rapidly increases in 
growth, and in many cases a marked improvement takes place 
in the mental condition. But to obtain this favourable result 
the treatment must be continuous, and it must be begun at a 
sufficiently early age. 

The effect of thyroid treatment is decidedly more uncertain 
and less pronounced upon the mental than the bodily develop- 
ment. To a great extent this appears to be dependent upon the 
age at which it is commenced, but there may be other factors 
which influence the result. Dr. G. A. Sutherland mentioned to 
me the case of one of his patients in whom the disease was diag- 
nosed at the age of three months, and who after continuous treat- 
ment for six years showed no mental impairment. Dr. Robert 
Hutchison tells me of a case of his which has been treated from 
the third month, and now, at the age of fifteen years, is appar- 
ently of normal mental capacity. Dr. George Murray, of New- 
castle, has also experienced such a satisfactory result. Dr. John 
Thomson has supplied me with particulars of a boy where treat- 
ment was begun at the age of seven and a half months, and who 
now, at the age of eleven and a half years, is so far improved that 
he reads and spells as well as the average of his age, his only 
noticeable weakness being in arithmetic. Another patient of 
Dr. Thomson's was started upon thyroid at the age of seven and 



Secondary Amentia and its Clinical Varieties 259 

a half weeks, and now, at six and a half years, is of normal 
appearance, somewhat above the average height, and, although 
not very energetic, appears to be of normal intelligence. Another 
case is that of a girl who has been under treatment since the age 
of four years eleven months. She reached the sixth standard at 
school, but never did much at arithmetic. She is now engaged 
as a compositor in a printing-office, but, owing to her slowness in 
lifting the type, only earns half the wage of other girls of similar 
age doing the same work. 

It must be admitted, however, that such cases are somewhat ex- 
ceptional and not the rule, and it is the general experience of those 
who have knowledge of these persons that the mental is rarely 
commensurate with the bodily development. I have in my care 
at the present time a patient who is an excellent illustration of 
this fact. He was sent to me at the age of eight years by Dr. 
Soltau Fenwick, with a letter to the effect that it was a case of 
cretinism which had been under treatment since infancy, and had 
improved wonderfully in all but the mental symptoms. I could 
detect absolutely no bodily sign of cretinism, and, instead of the 
torpid mental state characteristic of that condition, he was alert 
and active. But the boy was a pronounced imbecile, and he has 
made but little improvement under special training. In this case 
there is marked neuropathic heredity, and the mother has been 
insane in an asylum. Dr. Robert Hutchison tells me of a similar 
case which he has treated continuously since the seventh 
month, and yet the child is a hopeless imbecile, although not in 
the least like a cretin in appearance. Perhaps these instances 
represent the opposite extreme, for I think it is somewhat unusual 
for mental improvement to be so slight where treatment is 
begun thus early. 

In many patients improvement takes place at an even later 
age. Dr. Caldecott, of Earlswood Asylum, has at the present 
time in his care a cretin who was admitted at the age of fourteen 
years. She could not walk, talk, nor swallow solid food, and her 
mental status was that of a low-grade idiot. She had never been 
treated with thyroid. After three years' treatment she has grown 
12 inches, can walk and run about, talks fairly distinctly, and is 
taking her place in school. 

On the whole, I think it may be laid down that, whilst in some 

iy — 2 



260 Mental Deficiency 

cases cure may take place if treatment be initiated not later than 
the third month, should the first year be allowed to pass without 
thyroid administration, the cretin, although improving to some 
extent, will never make up his mental arrears. 

The most convenient method of treatment is by means of 
tabloids of the dried extract. Usually for a child of from three to 
six months a dose of \ grain once or twice daily will be found 
appropriate. This must be gradually increased at the rate of 
i grain per diem for each year of the child's age, with a maximum 
of 15 grains. Treatment must be continued after the symptoms 
have disappeared, or a relapse will ensue ; but usually an occa- 
sional large dose is sufficient to maintain the effect. 

The thyroid must be given cautiously at first, and the dose in- 
creased very gradually. In some cases it causes diarrhoea, rise 
of temperature, and marked acceleration of the heart, apparently 
as a result of the increased metabolism. It should then be dis- 
continued for a time, and again cautiously resumed. The exces- 
sive growth of the long bones may cause them to readily bend, 
and in order to prevent serious curvatures movement must be 
carefully supervised. 

In connexion with the subject of cretinism I may mention the 
following curious case of temporary cessation of mental and 
bodily development occurring in a girl at the age of puberty. I 
have never seen a similar case described, and the only explana- 
tion I can suggest is that for some reason or other the secretion of 
the thyroid gland was temporarily suspended. When I first saw 
the girl she was seventeen years of age, but in height, manner, and 
general development she had the appearance of a child of twelve 
or thirteen. Her mental condition was backward and corre- 
sponded to a similar age, and she had never menstruated. The 
mother informed me that the girl had seemed quite all right in 
mind and body until about four years previously, but since then 
she had been at a complete standstill. On examination the 
thyroid gland appeared to be normal, but the skin was sallow, 
coarse, dry, and had a curious boggy feel, the hair scanty, the 
mons veneris uncovered, the lips thick, and the teeth much 
decayed. There was also a pronounced flush over each cheek. 
She was extremely childish for her age, besides being unusually 
torpid in thought and movement. In view of these symptoms, 



Secondary Amentia and its Clinical Varieties 261 

I decided to try the effect of thyroid treatment. The mother 
noticed improvement after the first week, and after three months 
menstruation had appeared and a great change was evident in 
every way. She was under treatment for about nine months, 
and it was then discontinued entirely. The mental and bodily 
improvement initiated by the thyroid steadily continued, and 
when I last saw her, at the age of twenty-one years, she had a 
normal appearance, and was regularly employed as a clerk in 
the Post Office. 



AMENTIA DUE TO OTHER NUTRITIONAL DEFECTS. 

In addition to the secretion of the thyroid gland, it is possible 
that there may be other internal secretions or chemical com- 
pounds which are essential to the growth of the nerve cells, and 
the absence of which gives rise to mental deficiency. For 
instance, it may be that some such special defect is re- 
sponsible for the curious combination of bodily anomalies 
present in Mongolism. This, however, is mere conjecture. At 
present we know of no special nutritive agent other than the 
thyroid secretion, and the cases of amentia which we have now 
briefly to consider are those associated with a general defect of 
the bodily nutrition. 

A state of general malnutrition may be present during intra- 
or extra-uterine existence, and is by no means of infrequent 
occurrence. In some cases the cause is obscure ; in others the 
condition is obviously the result of insufficient or improper feed- 
ing, dirt, want of fresh air and sunlight, and general neglect. 
The atmosphere of ignorance, superstition, and indifference which 
surrounds the early infancy of a large number of the children of 
this country, particularly in large towns, is wellnigh incredible. 
In other cases the malnutrition is the result of actual disease, 
although this is more often than not due to preventable causes 
and an absolute ignorance or defiance of the laws of health. 

In view of the obvious effects which such adverse environment 
exercises upon the physical condition of the growing child, and 
being aware, from our knowledge of anatomy and physiology, 
of the immense importance of a copious and pure blood-supply 
to mental activity, it is not unnatural to conclude that serious 



262 Mental Deficiency- 

bodily malnutrition should have a deleterious effect upon the 
mental development of the infant. To a certain extent such a 
conclusion is correct. Although in many instances the ill-fed 
and ill-washed street gamin is far from unintelligent, experience 
does on the whole confirm the saying, Mens sana in corpore sano, 
and in a large proportion of such children the mental develop- 
ment is decidedly inferior to that of a healthy child of corre- 
sponding age. It is, however, necessary clearly to distinguish 
between mental development which is backward and delayed and 
that which is arrested. I have already referred to this subject 
in treating of mentally defective children, and pointed out that, 
whilst many of those suffering from delayed development closely 
simulate aments, there is in fact no real arrest, and under more 
favourable conditions the arrears are soon made up. It is prob- 
able that in some cases the deprivation of nourishment at a time 
when the cerebral neurones should be growing rapidly is so 
severe as to bring about permanent effects. I have, indeed, 
examined a few cases in which I could find no other cause. But 
in my opinion this is exceedingly uncommon. I have never 
known idiocy, or even imbecility, to result ; the mental deficiency 
is always mild, and the proportion of aments who owe their 
condition to bodily malnutrition is really infinitesimal. In some 
cases the malnutrition may play the part of an exciting factor, 
and be all that is needed to produce an actual arrest in a person 
whose neuronic potentiality is low as a result of morbid heredity. 
It has already been pointed out that a large number of primary 
aments suffer from defective bodily nutrition as a consequence 
of the improper working of their nervous system. It is very 
necessary to bear this fact in mind in considering this question, 
and to avoid mistaking cause for effect. 

One of the commonest disturbances of nutrition occurring in 
infancy is that due to rickets, and a " rachitic idiocy " has been 
described. I have never seen such a case. Rickets may, of 
course, complicate primary or secondary amentia, and there can 
be no doubt that the mental development of the rachitic child 
is often delayed and abnormal ; but, so far as my experience goes, 
rickets alone has never produced amentia. On the contrary, I 
know several adults of marked intellectual ability who show 
clear evidence of having suffered from severe rickets in childhood. 



Secondary Amentia and its Clinical Varieties 263 

With regard to cases of amentia due to congenital syphilis, as 
already stated, it seems to me more probable that these are the 
result of a direct toxic action than of a disturbance of nutrition. 



AMENTIA DUE TO ISOLATION OR SENSE DEPRIVATION. 

The growing brain cells not only require to be supplied with 
their own particular food, but they must also be stimulated by 
vibrations transmitted through the special sense pathways. The 
effect of these is probably similar to that produced by rays of 
light upon plant development, and in their absence cellular 
growth is as imperfect as if the brain had been starved. This is 
weJl shown by the marked agenesis of the occipital cortex which 
occurs as a consequence of congenital non-development of the 
organs of vision — a fact which has been ably utilized by 
J. S. Bolton to accurately map out the visual area. But not 
only are sensations thus necessary for growth : they are also 
the materials out of which thoughts and ideas are built, and 
the sum total of them constitutes mind. Should, therefore, 
a single sensory avenue be closed, as in blindness or deafness, 
the mind must for ever remain the poorer by the impressions 
which would have entered through this channel, and if two or 
more senses are defective the mind may be so impoverished 
as to bring about a condition of true amentia. 

As we have already seen, such sensory defects are occasionally 
present in primary amentia, and they are then a complication 
which usually imposes an insuperable obstacle to successful train- 
ing. In secondary amentia, however, which we are now con- 
sidering, there is no intrinsic incapacity of the cortical neurones, 
and if other sensory channels can be so utilized as to in some 
degree compensate for those diseased, the mental capacity may 
be but little impaired. Suitable training may therefore prevent 
secondary amentia from these causes. That this is so is fully 
shown by the excellent results achieved in training establish- 
ments for the blind and deaf, as well as by some classical examples 
in which disease of several sensory channels had existed. 

The common cause of the sensory deprivation in these 
cases is inflammation resulting from one or other of the in- 



264 Mental Deficiency 

fectious fevers ; the lesion is usually at the periphery, and the 
organs most frequently affected are those of sight and hearing. 
Amentia can only result when such occurs during early child- 
hood (whilst cerebral development is immature), and where 
special educational training has been withheld or has failed. In 
the absence of a neuropathic inheritance I believe failure to be 
exceedingly rare, and the cases of this form of amentia which are 
met with are nearly always in persons whose early education has 
been neglected. They are, in fact, as much sufferers from a 
deprivation of special education as of special sense. I have met 
several such cases in remote country districts. The child, 
deprived of sight or hearing in early life, is thereby excluded 
from the village school. The local authority provides no special 
form of education, and does not further concern itself with him. 
There may be institutions for the blind and deaf but ten miles 
away, but it is no particular person's business to secure him 
admission, and he gradually grows up without any training. 
He soon passes the age at which such would be of avail, and 
becomes an incurable ament. Although such a state of affairs 
still exists, it is less common than in years gone by. The neces- 
sity for, and great benefit to be derived from, training is now 
much more generally recognized, and in consequence cases of 
amentia due to sense deprivation are not nearly so prevalent as 
formerly. At the present time they comprise only a fraction of 
all cases of amentia, although the total number in existence is 
still considerable. 

These patients are usually well grown and free from any stig- 
mata of degeneracy. In the majority of instances the mental 
defect is mild, but it is not uncommon for it to be accompanied 
by hallucinations and delusions, and sometimes the behaviour is 
so erratic and untrustworthy as to necessitate committal to an 
asylum for the insane. 

Illustrative Cases. 

The two following are good examples of this form of amentia 
as commonly met with : 

Mild Amentia consequent upon Early Deafness. — W. S., male, 
fifteen years of age. No morbid heredity. Was either born deaf 
or became so shortly after birth, and has never spoken. He was 



Secondary Amentia and its Clinical Varieties 265 

refused admission to the village school, and has received no 
education. He is well grown for his age, and has a pleasing ex- 
pression. He can understand many signs, and can express 
many of his wants in the same way. Beyond helping his mother 
in the house at times, he is quite unemployed. He is by no 
means lacking in the faculties of imitation and imagination, and 
is fond of drawing on a slate or scraps of paper. It is quite evi- 
dent, however, that his ideas are extremely crude and childish. 
In addition to his intellectual defect, he has little power of con- 
trol, and is becoming more and more subject to outbreaks of 
passion and waywardness. On several occasions he has wandered 
away from home. His mother states that he is affectionate, 
but " cannot bear to be crossed." I am of opinion that in this 
case suitable training in a school for the deaf would have pre- 
vented the mild amentia now present, and would have resulted 
in the patient becoming a useful member of society. Even at this 
age I strongly urged the desirability of such training, as with- 
out it there is no doubt that he will gradually become more 
intractable, and will finally drift into an insane asylum. 

The Earlswood case also is probably one of amentia due to 
deafness, but as this patient has developed a most extraordinary 
degree of mechanical skill, I have thought it better to describe 
him under the chapter on Idiots Savants. 

Mild Amentia consequent upon Congenital Blindness. — E. W. C, 
male. Born blind. No education. Admitted into imbecile in- 
stitution at the age of fifteen, but found to be intractable and 
violent, and transferred to lunatic asylum. 

He is now twenty-nine years of age, and is a tall, well-developed 
and well -nourished man of pleasing expression. Cranial circum- 
ference, 22| inches. No stigmata of degeneracy. He is quite 
blind, the eyes being represented by rudimentary bulbs of white 
sclerotic tissue without any indication of cornea or iris. His 
memory is good ; he has a tolerably good knowledge of places and 
events, can understand all that is said to him, and can give a 
fair account of himself. He possesses imagination, but his ideas 
are simple and childish, and his power of reasoning is decidedly 
defective. He cannot read, write, sum, or do any kind of work, 
and he spends the day rocking himself to and fro in a chair 
and muttering to himself. After answering a question, he 



266 Mental Deficiency 

rambles on to himself in an incoherent way about analogies 
and philosophy. When asked what a philosopher is, he says : 
" A man who tries to make everybody else better." He then 
immediately goes on to talk about Ally Sloper, which, he says, 
has been read to him. He has aural hallucinations and delusions, 
and is very emotional and untrustworthy. In spite of his beatific 
appearance, he is liable to frequent outbreaks of sudden violence, 
and has repeatedly attacked the other patients. He is also a 
confirmed masturbator. (See Plate XXII., Fig. 53.) 

The following well-known cases may be briefly referred to in 
this place, as showing the really remarkable results which may 
attend the systematic education of patients suffering from severe 
sense deprivation. 

Laura Dewey Bridgman.* — An attack of scarlet fever at the 
age of two years caused suppuration of both eyes and both ears ; 
taste and smell were also impaired. She was quite deaf, and sight 
was entirely abolished in the left eye ; but she retained a slight 
perception of light in the right eye up to the eighth year, after 
which she became completely blind. She was admitted to the 
Perkins Institution for the Blind at Massachusetts at the age 
of seven years ten months, and received systematic education 
under Dr. Howe until she was twenty. Owing to the unremitting 
care and patience of Dr. Howe in training her cutaneous sensation 
(the only sense unimpaired), she became able to read and write 
in the deaf and dumb language, to express many of her feelings, 
to sew, knit, and perform certain household duties, and, in short, 
to live to a great extent the life of an ordinary person. She 
remained in the Perkins Institution until her death, at the age 
of sixty years. The general conclusion arrived at regarding her 
by Mr. Sangford was that "she was eccentric, not defective; 
she lacked certain data of thought, but not in a very marked way 
the power to use what data she had." 

* See the " Life of Laura Bridgman," by M. S. Lamson, Boston, 1878 ; 
also an account by Dr. Howe in the Forty-Third Annual Report of the 
Perkins Institution and Massachusetts Asylum for the Blind. A very 
good abstract of this is given by Dr. Ireland in his " Mental Affections of 
Children." 

The brain was very carefully examined by Dr. H. H. Donaldson, and 
described by him in the American Journal of Psychology, September, 1890, 
and December, 1891. 



Plate XXII. 







<^: 



<-W C 



j»3 

r- c 

71 

32 




7^ /rtictf f>age 266. 



Secondary Amentia and its Clinical Varieties 267 

The post-mortem examination showed that the auditory 
nerves, the optic nerves and tracts, and the olfactory bulbs, were 
very small. The grey matter of the cortex generally was thinner 
than usual, especially in the occipital, cuneus, and temporal 
lobes. In these situations there was also a deficiency in the 
number of nerve cells. There was a considerable non-develop- 
ment of the inferior frontal and temporo-sphenoidal convolu- 
tions covering the island of Reil, particularly marked on the left 
side. The cranial circumference was 20 '8 inches. 

In two other pupils of the Perkins Institution — namely, Oliver 
Caswell and Helen Keller — the results were almost equally 
remarkable. The former of these was blind and deaf from infancy, 
and the latter lost sight and hearing at the age of nineteen 
months. 

Meystre, of Lausanne (Switzerland), was born deaf and dumb, 
and he lost his sight by an accident at the age of five years. 
By unremitting attention he was taught to articulate, and at 
the age of eighteen he was described as " a lively, intelligent, 
and good-humoured fellow, an excellent carpenter, a first-rate 
turner, and runs about the building with a certainty and confi- 
dence which none of the merely blind pupils acquire. He has a 
great many ideas, and an instinctive dread of death." 

Agnes Halonen* was born in Finland in 1886. At the age of 
eighteen months she became blind from scarlet fever, and a year 
afterwards became deaf. She very soon ceased to speak, and 
expressed her wants by means of a few simple signs, such as 
putting her hand to her mouth when she wanted food. She 
could recognize members of her family by touch. At the age of 
eight she was sent to the Blind School at Helsingfors. Here she 
was taught to sew and knit, as well as the finger alphabet. At 
the age of seventeen she could read books in Braille and Moon's 
characters, and she could also write. She had some knowledge 
of geography, which had been taught her by means of raised 
maps. She knew many of the capitals, mountains, and rivers 
in Europe and Asia, and she had a knowledge of the habits of 
plants and animals. She was able to sew, spin, crochet, plait, 
and make brushes, and generally was very intelligent. 

* " The Blind Deaf -Mute, Agnes Halonen," by Aug. Helin, Stockholm. 
Abstract in Journal of Mental Science, April, 1904, p. 336. 



268 Mental Deficiency 

Kaspar Ha user. — Xo account of this subject would be complete 
without a brief reference to this celebrated and mysterious case. 
It differs from the foregoing in that there was no disease of the 
sensory pathways, but the environment of the child for many 
years was such that they could not be exercised. It may fittingly 
be described as a case of mental arrest due to isolation. 

On May 26, 1828, a youth, apparently about sixteen or seven- 
teen years of age, was found near one of the gates of Nuremberg. 
He was unable to give any account of himself, and inquiries 
failed to discover how or whence he came or who he was. He 
was 4 feet 9 inches in height, very pale, with short, delicate beard 
on his chin and upper lip. His feet were tender and blistered, 
and showed no signs of having been confined in shoes. He 
scarcely knew how to use his fingers or hands, and his attempts 
at walking resembled the first efforts of a child. He could not 
understand what was said to him, and replied to all questions by 
a single phrase : " I will be a trooper, as my father was." His 
countenance was expressive of gross stupidity. He appeared to 
be hungry and thirsty, but refused everything offered to him 
except bread and water. He held in his hand a letter stating 
that the bearer had been left with the writer, who was a poor 
labourer with ten children, in October, 1812, and who, not 
knowing his parents, had brought him up in his house, without 
allowing him to stir out of it. This was regarded as being 
intended to deceive. Upon a pen being place in his hand, the 
youth wrote the words " Kaspar Hauser." 

After an official inquiry — which, however, revealed nothing — 
he was adopted by the town of Nuremberg, and Professor Daumer 
undertook his education. He was found to be extremely child- 
like, and to have no knowledge of the most simple facts of every- 
day life. He had a remarkable faculty of smell and for seeing 
things in the dark, however, and under the instruction of Daumer 
his mind expanded in a wonderful manner. In fact, probably 
as a consequence of its sudden awakening into activity, he 
became ill, and his education had to be discontinued for a time. 

He was taught the use of language, and after a time was able 
to record his recollections. He said that he had always lived in a 
small, dark cell, continually seated on the ground. He had had 
no covering, except a shirt and trousers, and had never seen the 



Secondary Amentia and its Clinical Varieties 269 

sky. When he awoke from sleep he was accustomed to find near 
him some bread and a pitcher of water, but he never saw the face 
of the person who brought them, and he had no knowledge that 
there were any other living creatures besides himself and the 
man who brought him food. This man eventually taught him 
to write his own name, and finally brought him to the Nuremberg 
gate. 

For a time mental development took place with great rapidity, 
but the prolonged isolation had wrought an effect upon the brain 
cells from which they could not completely recover, and after a 
time their potentiality became exhausted and no further progress 
was made. He was taken under the protection of Lord Stanhope, 
and he was subsequently employed in the Court of Appeal, but 
he showed little real capacity for work. On October 17, 1829, 
he was found bleeding from a slight wound which he said had been 
inflicted by a stranger. On December 14, 1833, at Anspach, he 
met a stranger by appointment, on the promise that the mystery 
of his birth would be revealed. During the interview he was 
mortally stabbed, and he died three days afterwards. 

A post-mortem examination showed a somewhat thickened 
skull and rather small brain, which did not completely overlap 
the cerebellum. The convolutions of the brain were also simpler 
than normal. 

The mystery of Kaspar Hauser's birth and death attracted 
widespread interest, and has never been solved. It was con- 
tended by Earl Stanhope and the Duchess of Cleveland that he 
was an impostor, but this view was strongly combated by both 
Professor Daumer and the eminent Bavarian jurist, Von Feuer- 
bach. The latter considered that Hauser was heir to a princely 
German house, put out of the way to favour another succession. 
A careful examination of the facts regarding his condition when 
first found, his subsequent limited progress, his untimely and 
mysterious death, and the state of his brain, seem to show that 
his account was a truthful one, and that he exemplifies in a unique 
manner the effects of a prolonged isolation upon the cells of the 
brain. 



CHAPTER XIV 

IDIOTS SAVANTS 

We have seen that amentia is often characterized by an irregular 
as well as a defective mental development, and in a small number 
of patients this is so marked as to result in special aptitudes 
which are quite phenomenal, not merely in comparison with 
aments, but often with the acquirements of ordinary persons. 
These persons are conveniently described as "idiots savants." 
The condition is exceptional and relatively uncommon ; on the 
other hand, it is not so rare but that a considerable number of 
cases have been recorded. 

Presumably the special aptitude is related to an increased de- 
velopment of certain cerebral neurones, but as to how and why 
this is brought about we can only conjecture. In many of the 
cases I have seen there has been a clearly marked predilection 
(which, however, has rarely been marked in the ancestors), and 
I can only assume that this is the result either of some primary 
developmental anomaly or of some fortuitous circumstance of 
early life which has aroused the child's interest in a particular 
direction, and thence led to the concentration of all his mental 
activities upon the one object. On the whole, I think that most 
of these cases are explicable on this latter view. The talent, 
whatever it is, and however originating, certainly owes much of 
its development to constant exercise. 

It is to be noticed that although these persons are spoken of 
as " idiots," they are rarely of the lowest grade of mental defect. 
Most of them would more properly be classed as imbeciles or 
merely feeble-minded. It is remarkable, however, that they 
almost invariably belong to the male sex, female idiots savants 
being almost unknown. 

270 



Idiots Savants 271 

Peterson is of opinion that the talents of these persons lie 
chiefly in the direction of imitation, and that they have no 
capacity for origination. He also thinks that they are frequently 
lost before adult life. These statements are undoubtedly true 
of many cases, but they are by no means invariable. I doubt 
whether the latter one is even the rule, and several illustrations 
to the contrary will be cited in the following pages. 

The nature of these phenomenal acquirements varies con- 
siderably. In some persons the talent consists of an extra- 
ordinary development of one of the special senses. Thus, Jules 
Voisin describes the case of an imbecile with a wonderful delicacy 
of smell. She never ate or drank anything without smelling it, 
and if given coffee (for which she had a great fondness) in a glass 
which had contained wine, she would at once detect it and refuse 
to drink. Imbeciles have been described who were able by the 
sense of smell to pick out their own and their companions' clothes, 
and Seguin noticed many idiots even, in whom this faculty was 
developed to an extraordinary degree. 

In other cases there is an increased development of the visual 
sense. Several of the drawing and mechanical geniuses have a 
wonderful capacity for detecting slight differences of form and 
size, whilst the following case, mentioned to me by Dr. R. Langdon 
Down, is an excellent example of this class. It is that of a boy, 
a patient at Normansfield, whose hobby was the collection of small 
bright articles of any description, and this interest had so cul- 
tivated his quickness and sharpness of sight that nothing in the 
shape of a pin, a minute fragment of broken glass, or any shining 
particle, which was invisible to the ordinary person, ever escaped 
him. Other patients have a phenomenal auditory capacity — as, 
for example, the wild boy of Aveyron described by Itard, as well 
as some who will presently be mentioned on account of their speech 
and memory. Finally, there are some cases in which the hyper- 
development concerns the tactile sense. Dr. R. Langdon Down 
tells me that there used to be a boy at Normansfield whose sense 
of touch was so delicate and fingers so deft that he could take a 
page of the Graphic and gradually split it into two perfect sheets, 
as one would peel a postage stamp off an envelope. 

In another group of cases it is chiefly in the motor functions 
that these extraordinary talents he. Sometimes there is an 



272 Mental Deficiency 

almost incredible capacity for the performance of mechanical 
work requiring the greatest cunning and dexterity, and as an 
example of this the Earlswood case, which will presently be 
described, is probably unique. In other persons the gift takes 
the form of drawing, and many of the walls of Earlswood Asylum 
are at the present time adorned by beautifully executed crayon 
drawings (copies of well-known pictures) which were done by the 
mentally deficient brother of the patient just referred to. Occa- 
sionally the talent for drawing passes beyond mere picture-copy- 
ing, as in the celebrated case of Gottfried Mind. This person, 
who died at Berne in 1814, was a cretin imbecile with such a 
marvellous faculty for drawing pictures of cats that he was known 
as " Der Katzen-Raphael." 

Under the heading of motor we may also describe those cases 
possessing, if not the gift of tongues, at all events an extra- 
ordinary capacity for reproducing spoken words. Dr. Martin W. 
Barr* describes an epileptic idiot, aged twenty-two years, who, 
in spite of the most careful teaching, could learn neither to read 
nor to write, although he was able to perform small domestic 
duties. Spontaneously he hardly spoke at all, and then only 
short disconnected words or the simplest sentences ; but he had 
an extraordinary capacity for repeating fluently and with proper 
intonation everything said to him, whether in his mother-tongue 
or in such languages as Greek, Japanese, Danish, Spanish, etc. 
Probably those cases in which an imbecile will reel off, verbatim, 
cantos of poetry also belong to this category. 

In a considerable proportion of these idiots savants the gift is 
one of memory in some form or other, and of this many interesting 
and remarkable examples have been described. At the present 
time there are two such in Earlswood Asylum. One of them is a 
man, sixty-five years of age, suffering from high-grade amentia, 
whose penchant is biographical history. It is only necessary to 
mention to him the name of any prominent personage in early or 
ancient history, and out there flows in a steady, unhesitating 
stream a full and detailed account of his birth, life, and death. 
His knowledge has been acquired by poring over biographical 
details in such books as were available, and is, of course, simply 

* M. W. Barr, "Some Notes on Echolalia," Journal of Nervous and 
Mental Diseases, January, 1898. 



Idiots Savants 273 

a matter of memory. It is not, however, merely repetitive, for 
he stands cross-questioning in a manner which shows that he 
has some knowledge, although not full understanding, of the 
occurrences he is talking about. Dr. Caldecott tells me that 
until the last few years there has been no decline in this man's 
capacity ; latterly, however, he has begun to show signs of mental 
and bodily old age. The other case is a somewhat younger man, 
aged fifty-six years, whose memory also relates to dates and 
occurrences, but only such as have come under his own notice. 
He is a most valuable referee on matters connected with the 
previous life of the institution, and can repeat the year, month, 
and day of coming and going, of all the medical officers during 
his period of residence. 

Dr. R. Langdon Down showed me a similar case at Normans- 
field, the patient being a high-grade imbecile thirty-eight years 
of age. In this case the phenomenal memory chiefly relates to 
number, but the patient also has a pronounced sense of locality. 
His speciality is the calendar, and if given any date during the 
last five years, he states the correct day without any hesitation. 
But he seems almost equally at home with the hymn-book, and 
will promptly give the number of any hymn of which he is given 
the first line, or vice versa. His home is near Maida Vale, and 
on being asked what streets he would have to pass through in 
going home from Waterloo terminus he named each one without 
the slightest hesitation. This patient can also give the product 
of any two numbers under twenty with the rapidity of a reflex 
movement. 

Dr. Forbes Winslow* mentions the case of a man who could 
remember " the day when every person had been buried in the 
parish for thirty-five years, and could repeat with unvarying 
accuracy the name and age of the deceased, and the mourners 
at the funeral. But he was a complete fool. Out of the line 
of burials he had not one idea, could not give an intelligible 
reply to a single question, nor be trusted even to feed himself." 

Other cases show the existence of this phenomenal memory in 
its simplest automatic form. Thus, there are many idiots who 
cannot speak a single word, and yet can hum a tune, which they 
have only heard once, with perfect accuracy. Other aments will 

* Quoted by Ireland. 

18 



I 



274 Mental Deficiency 

reel off poetry almost ad infinitum, yet without any understand- 
ing of the sense of what they are saying, or even the meaning of 
the words. Dr. Langdon Down has described the case of a boy 
who, having read a book, would correctly recite whole pages 
word for word. Dr. Maudsley mentions the case of an imbecile 
who could similarly repeat verbatim a newspaper he had just 
read, as well as another more remarkable patient who could 
repeat backwards what he had just read. 

Most aments are fond of music, and some particularly so, but 
in a few instances this propensity has an extraordinary develop- 
ment. One of the most striking examples of this is furnished 
by Dr. Trelat, and this case is also interesting in being a female. 
Dr. Trelat* says that " they had in the Salpetriere an imbecile 
born blind, affected with rickets, and crippled, who had great 
musical talents. Her voice was very correct, and whenever she 
had sung or heard some piece she knew perfectly well the words 
and the music. As long as she lived they came to her to correct 
the mistakes in singing of her companions ; they asked her to 
repeat a passage which had gone wrong, which she always did 
admirably. One day, G£raldy Liszt and Meyerbeer came to the 
humble singing-class of our asylum to bring her their encouraging 
consolations." Dr. Seguin also records several cases in which a 
pronounced musical capacity was present. 

Lastly, in marked contradiction to the general failing of aments 
in this respect, a few of these persons have an extraordinary 
capacity for arithmetic and calculations. One case described 
by Dr. J. Langdon Down is that of an inmate of Earlswood 
Asylum, an imbecile boy of twelve years, who could multiply 
three figures by three other figures with lightning rapidity. 
Dr. Howe has also recorded the case of a low-grade ament who, 
if told the age of anyone, would in a very short time calculate 
the number of minutes he had lived. Dr. Wizelf also records 
the case of an imbecile (apparently suffering from secondary 
amentia) who had a most remarkable faculty for arithmetic, 
particularly multiplication. 

We may conclude this chapter on idiots savants with an account 
of the following extremely interesting case : 

* Trelat, "La Folie Lucide," etc., Paris, 1861. Quoted by Ireland, 
•j- Archiv ftir Psychiat., Band xxxviii., Heft i. 



Idiots Savants 275 



The Genius of Earlswood Asylum. 

Since the year 1850 there has been resident in Earlswood 
Asylum a patient who has justly earned this title, and whose 
skill in drawing, invention, and mechanical dexterity is certainly 
unequalled by an inmate of any similar institution in existence. 
At the present time, although seventy-three years of age, he still 
continues to be actively engaged in his workshop. I am greatly 
indebted to Dr. Caldecott for his kindness in giving me permis- 
sion to examine this patient and his wonderful productions ; also 
for freely placing at my disposal a mass of particulars and photo- 
graphs regarding him which he has taken great trouble to collect. 
/. H. Pullen was born in the year 1835. The family history 
is somewhat scanty, for the reason that the only informant now 
available is the patient's sister ; but, as far as can be ascertained, 
the parents and grandparents were steady, sober, hard-working 
people, and there is no history of insanity, epilepsy, or any of 
the usual antecedents of primary amentia. The parents, how- 
ever, were first cousins. Of thirteen children born in the family, 
six died in infancy, and of the remaining seven only three are 
now living. It is extremely interesting to note that another 
brother was deaf and dumb, and had an even greater aptitude 
for drawing than the patient ; he died in Earlswood Asylum of 
cancer at the age of thirty-five years. 

There are no particulars as to the age at which the patient 
began to walk, but he did not talk until seven years, and for a 
long time only uttered the word " muvver." He never went to 
school, as no school would take him. He showed an early taste 
for drawing, and used to spend the greater part of his time at 
this occupation or in carving ships out of bits of firewood. Such 
instruction as he had he received from his parents and brothers 
and sisters at home, and from these he learned to write and spell 
the names of simple objects, but this was practically the sum 
total of his scholastic acquirements. 

Pullen was admitted to Earlswood Asylum at the age of fifteen 
years. On admission he was found to be active and well 
grown, his height being 5 feet 7 J inches, and his weight 9 stones 
11 pounds. The cranial circumference was 21J inches. He was 

18—2 



276 Mental Deficiency 

described as having a good memory and power of imitation, and 
as being fond of drawing and examining how things were made. 
His senses of taste, smell, and touch were good ; he was able to 
wash, dress, and take care of his person, but his speech was very 
imperfect and he was very deaf. 

He was put to work in the carpenter's shop, and soon became 
an expert craftsman. It was clear, moreover, that he possessed 
a capacity for initiation, imagination, resource, and attention far 
above the other inmates, and in consequence he was allowed 
considerable liberty of action and freedom to follow his own bent. 
The result, after sixty years, is to be seen in the fifty to sixty 
crayon drawings, the carvings in ivory and wood, and the wonder- 
ful models of ships and the like, which to-day adorn the walls and 
fill the two large workrooms placed at his disposal in Earlswood 
Asylum. Some idea of his skill in drawing and mechanical in- 
vention will be gathered from the accompanying photographs of 
his work (Plates XXIII., XXIV., XXV.), but, as Dr. Caldecott 
very truly says, it is difficult by this means to really appreciate 
their beauty, to do which the originals must be seen. 

Pullen has designed and drawn a pictorial history of his life, 
which shows his chief occupations between the years 1841 and 
1873. A reproduction of this is given in Fig. 55. 

One of the most wonderful of his works, and the one of which 
he is the most proud, is the model of a steamship which he has 
named the Great Eastern. This, I think, he rightly regards as 
his magnum opus, and it attracted universal admiration at the 
Fisheries Exhibition, where it was shown in the year 1883. It 
took him three years and three months to complete, and every 
detail, including brass anchors, screw, pulley-blocks, and copper 
paddles, were actually made by the patient from careful drawings, 
which he prepared beforehand. The planks of this leviathan are 
fixed to the ribs by wooden pins to the number of nearly a million 
and a quarter. All of these were made by Pullen in a special 
instrument, which in turn he also planned and made. He also 
devised and executed a strong carriage on four wheels for the 
conveyance of the ship. The model is 10 feet long, i8f inches 
wide, and 13! inches in depth. It contains 5,585 copper rivets, 
and there are thirteen lifeboats hoisted on complete davits, each 
of which is a perfectly finished model. It is fitted with paddles, 



Plate XXIII. 










£J2 

a o 



■si 



2 



To face page ■2-j^.\ 



Idiots Savants 277 

screw, and engines, and it contains state cabins, which are 
decorated and furnished with chairs, tables, beds, and bunks. In 
fact, the whole thing is complete to the most minute detail, and 
will bear the closest inspection. (See Fig. 59.) He has invented 
and attached an arrangement of pulleys by which the whole upper 
deck may be raised so as to show the parts below. I believe 
that when first put into water the huge model capsized, but that 
has since been remedied. It is perhaps hardly to be expected 
that a person with no knowledge of practical boat-building should 
succeed in making a vessel that would be really navigable, but 
as a highly finished model it is unmatched in its completeness. 

Another of Pullen's productions is an immense but most beauti- 
fully finished kite in the form of a ship under full sail. Another 
is a fully rigged man-of-war of the old wooden type. This is 
copper- riveted, and contains forty-two brass cannon, all of which 
were made by the patient. The rigging contains 200 pulley-blocks, 
all capable of working. (See Fig. 57.) Another production, which 
testifies to his imaginative as well as mechanical faculty, consists 
of a fantastic barge most beautifully carved out of ivory, ebony, 
and various fancy woods. Upon the prow are seated four angels 
carved out of ivory, whilst the stern is occupied by a figure of 
His Satanic Majesty. There are twelve oars, beautifully jointed, 
and worked mechanically from one centre rod. 

One of his most recent pieces of work is the representation of 
a monstrous human form about 13 feet high. This black-bearded, 
terrible-looking figure is armed with a gigantic sword, and can 
be made to perform a variety of movements, such as opening and 
shutting the mouth and eyes, protruding the tongue, rotating 
the head, raising the arms, etc., by means of a most elaborate 
internal mechanism. It is calculated to strike terror into the 
heart of any juvenile beholder. Of this, with the White Knight, 
he may truly say, " It's my own invention." 

Other productions include bookcases, chairs, tables, work- 
benches, picture-frames, and the like ; in fact, the list of his work 
during the fifty-eight years he has been in the asylum would 
alone fill several pages of this book. 

In disposition Pullen is usually quiet, well-behaved, and good- 
tempered, and he seems to be perfectly happy so long as he is 
allowed to work out his own ideas when and how he pleases. 



278 Mental Deficiency 

He is intolerant of supervision, inclined to be suspicious of 
strangers, and easily affronted by injudicious busy-bodies. At 
times he gets a little out of hand, and if denied requests which 
are quite unreasonable is apt to become sulky or passionate. 
On one occasion he threatened to blow up the place because a 
request had been refused, and it is quite likely that he would 
have attempted to do so had he not been mollified. On another 
occasion he did actually partially wreck his workshop in a fit of 
passion. Many years ago there was a steward of the asylum to 
whom Pullen took a violent dislike, and he spent many days 
planning his destruction. This culminated in the erection over 
the door of a most diabolical instrument, which was intended to 
guillotine the unfortunate officer, and there is not the slightest 
doubt that it would have done so had it not gone off a fraction 
of a second too late. 

He once became enamoured of a female whom he had chanced 
to meet outside the asylum. Nothing would satisfy him but 
that he should have his discharge and be allowed to marry her. 
He moped about, utterly refused to do any work or to listen to 
argument or persuasion, and it became clear that the position 
was critical. A happy inspiration occurred to a member of the 
committee, and a gorgeous naval uniform, resplendent in blue 
and gold, was procured. Pullen was invited into the board-room 
and informed that his case had been carefully considered, and 
that it had been decided to accede to his request. At the same 
time it was pointed out to him that the committee would be 
exceedingly sorry to lose his valuable services, and that, if he 
would reconsider the matter, they would, as an alternative, 
grant him a commission as Admiral in the Navy. The uniform 
was then shown to him as an earnest of their intention. This 
was too much for Pullen ; he took the uniform, and has never 
since alluded to the subject of marriage. This uniform he usually 
dons on ceremonious occasions. (See Fig. 54.) 

A note in the case-book describes him as " the quintessence of 
self-conceit," and a consuming vanity and almost overwhelming 
sense of his own cleverness and importance are very marked 
characteristics. Whilst showing me his handiwork he frequently 
stopped to pat his head and say, " Very clever "; and when I 
produced a tape measure and asked permission to ascertain the 



Plate XXIV. 
PRODUCTIONS OF THE "GENIUS" OF EARLS WOOD ASYLUM. 




FlG. 56. — A crayon copy of the celebrated picture "Bolton Abbey.' 




Fig. 57. — A fully-rigg-ed man-of-war of the old wooden type, and carriage, with the maker, 
To face page 278.] 



Idiots Savants 279 

extent of his cranial capacity he was delighted, and evidently 
regarded me as a very sensible fellow. At the same time, in 
spite of his childish egotism, he is by no means deficient in some 
power of looking after himself, and on several occasions he has 
been found selling privately and for his own advantage little 
articles he has made. Many of his works are carried out under 
the real or pretended idea that he has a commission for them at 
a contract price, and this childish fancy, as well as his extremely 
limited vocabulary, is illustrated by his private memorandum- 
book, the photograph of a page of which is shown in Fig. 58. 

What conclusion are we to come to regarding the causation 
and pathology, even the mental status, of this remarkable man ? 
His powers of observation, comparison, attention, memory, will, 
and pertinacity, are extraordinary, as is fully shown by the fore- 
going account ; and yet he is obviously too childish, and at the 
same time too emotional, unstable, and lacking in mental balance, 
to make any headway, or even to hold his own, in the outside 
world. Without some one to stage-manage him, his remarkable 
gifts would never suffice to supply him with the necessities of 
life, or even if they did, he would speedily succumb to his utter 
want of ordinary prudence and foresight and his defect of com- 
mon sense. In spite of his delicacy of manipulation he has never 
learned to read or write beyond the simplest words of one syllable. 
He can understand a little of what is said to him by lip-reading, 
and more by signs, but, beyond a few words, nearly all that he says 
in reply is absolutely unintelligible. 

My own conclusion, based upon several interviews and upon 
the particulars supplied me by Dr. Caldecott, is that the case is not 
one of primary amentia at all, but that it should really be classed 
as an example of mild secondary mental deficiency due to sense 
deprivation (deafness). Whether this deafness is the result of a 
congenital deficiency of the auditory mechanism or is due to 
disease I am unable to say, as the particulars of his early life are 
unfortunately very meagre ; but I am inclined to think that it 
was owing to this deprivation that he was refused admission to 
school, that he was to a great extent cut off from intercourse 
with his fellows, and that he grew up uninstructed in, and 
ignorant of, ordinary scholastic attainments and the ways of 
the world. Left largely to himself, his amusement consisted in 



1 



280 Mental Deficiency- 

copying drawings and carving bits of firewood, as I have seen 
in other cases of early deafness. His isolated condition caused 
all the powers of his mind (which do not seem to me to have been 
intrinsically defective) to be devoted to, and concentrated upon, 
these occupations, with the result that he developed a power of 
copying drawings, of carving in wood (and later in ivory), and 
a general mechanical dexterity of the very highest order. The 
curious combination of extreme ability in these particulars, with 
his general childish simplicity, his egotism, suspicion of strangers, 
sullen or passionate outbreaks if thwarted, and, in fact, the 
whole of his mental characteristics, are, I think, explicable in 
this view. The condition is similar in kind, although differing 
in degree, to that frequently seen in neglected cases of congenital 
deafness, and it is not greatly dissimilar to that of some non- 
idiotic savants who, absorbed in their one particular subject, 
have gradually lost interest in, and severed their connexion 
with, the outer world. 



Plate XXV. 
PRODUCTIONS OF THE "GENIUS" OF EARLSWOOD ASYLUM. 



£0. 






4-3 



-J, 



**r+ 






i4% 






\ /<FS/. ' 

\ / at* ff " 

* 325,1 ! i 
/M£J / i 






X% 



•M//441, 







/<?£ 








"("/:■-■■ 



i 



Fig. 58. — Photograph of the first page of the patient's private memorandum book. 




Fig. 59. — The Great Eastern, with its carriage, as exhibited at the 
Fisheries Exhibition, 1SS3. (For description see Text.) 
To face page 280.] 



CHAPTER XV 

THE AMENT AND SOCIETY— PAUPER AMENTS 

Hitherto we have been chiefly concerned with aments as indi- 
viduals ; in the next three chapters it is proposed to deal with 
them as members of the community, and to refer to such of their 
characteristics as concern their relationship to society. Until the 
last few years no reliable, and at the same time extensive, statistics 
referring to the ament as a citizen have existed. The extremely 
valuable ones we now possess are due in great measure to the 
investigations instituted by the Royal Commission of 1904.* Of 
these I shall make full use. I know of no similar inquiry or 
statistics concerning any other country. 

Location of the Mentally Deficient. 

We may first of all consider the location of these persons. 
This is shown by Table V. on p. 12, which relates to eleven 
selected areas of England and Wales, having an aggregate 
population of 2,321,567. The areas investigated were the three 
large towns of Manchester, Birmingham, and Hull ; the two 
industrial areas of Stoke-upon-Trent and part of the mining 
county of Durham ; two mixed industrial and agricultural areas 
in Carmarthenshire and Nottinghamshire ; and four rural areas in 
Somersetshire, Wiltshire, Lincolnshire, and Carnarvonshire. The 
selection is thus representative of the entire country. This table 
is based upon the returns of the Royal Commission, to which, 
however, are added those aments confined in county and borough 
asylums, and certified under the Lunacy Act, these not being 
included in the Commission's inquiry. 

It is seen from this table that the total number of aments 
* See Report of the Royal Commission on the Care and Control of the 
Feeble-Minded, particularly vol. vi., dealing with the medical investigations. 

281 



282 Mental Deficiency 

resident in institutions or in receipt of outdoor relief — that is, 
wholly or partially supported by the public (Classes A and B) — is 
40-5 per cent, of the whole number. A few of those in asylums are 
probably paying patients, but their number is so small as to be 
negligible. But this proportion is relative to a total which 
includes the juvenile feeble-minded in schools, and there can be 
no doubt that a large number of these, upon attaining the age 
of sixteen years, will go to swell the ranks of the pauper class. If 
these mentally defective school-children be excluded, it is found 
that the number partially or entirely supported by the public in 
each respective degree of amentia, is as follows : Feeble-minded 
adults, 67 per cent. ; imbeciles, 52 per cent. ; idiots, 54 per cent. 

The proportion of aments who, to all intents and purposes, 
may be looked upon as paupers is thus seen to be a large one, but 
this is only what would be expected in view of their mental 
disabilities, often combined with antisocial propensities, which 
we have already described. It will be of interest to consider 
the degrees of amentia separately. 

Feeble-minded. — With regard to the adult feeble-minded, it is 
a striking fact that nearly two-fifths of the total number dis- 
covered were found within Poor-Law institutions. From careful 
inquiry into the history of those in the Somersetshire area, I found 
that they fell into the following groups, and the same is probably 
true of the country generally : 

(a) Those born in the House, nearly always illegitimate. 

(b) Those admitted in consequence of inability to earn their 
living. Most of these are below middle age ; they include vagrants 
and street loafers brought in by the police, and a small section of 
" ins-and-outs " driven in by stress of weather. 

(c) Those admitted in consequence of the death of parents or 
relations who have hitherto looked after them. 

(d) Women admitted into the maternity wards. 

The economic disadvantage of such a large proportion of 
these persons being resident in workhouses is obvious when it is 
stated that the majority are not in the declining years of life, but 
are young adults, and that comparatively few of them are re- 
muneratively employed. 

The inquiries show that more than half are below forty-five 
years of age, whilst from one-fourth to one-third are below thirty. 



The Ament and Society — Pauper Aments 283 

It was the general experience of the investigators that more were 
admitted between the ages of twenty and thirty years than 
during any other decade. This tendency for the feeble-minded 
to drift into the workhouse quite early in life is even more pro- 
nounced in the large towns, and Dr. Melland found that in Man- 
chester less than one-quarter of the total number were over fifty 
years of age, " in marked contrast to the normal-minded able- 
bodied inmates, the vast proportion of whom are above that age." 

With regard to the employment of these persons, Dr. W. A. 
Potts, speaking of Birmingham, says : "A certain amount of 
employment is found for adult male defectives, who are taught 
boot-making, mat-making, and rope-making. Such work might 
be extended in this and similar institutions with advantage. It 
is an important proof of what can be done in workhouses. " 
Possibly the same obtains in a few other Poor-Law establishments, 
but of the great majority throughout the country it must be 
said that there is very little attempt to employ these persons to 
any economic advantage, and I believe that the conditions which 
I found to exist in Somersetshire are very general. There I found 
that about half the male feeble-minded were more or less (generally 
less) usefully engaged in coal-carrying, wood-chopping, and the 
ordinary domestic work of the institution, whilst about two-thirds 
of the females were doing a little scrubbing, mending, and laundry 
work. The remainder were idle, and simply loafed about, many 
of them being either incorrigbly lazy or requiring so much super- 
vision that they were more bother than they were worth. 

In fact, the presence of such a large proportion of feeble-minded 
persons in workhouses is not due to any definite administrative 
attempt to provide for this class, or even to the suitability of 
these institutions. It is solely and simply a result of the inevitable 
tendency for the non-supervised ament to drift out of life's stream 
into the nearest backwater. I calculate that about 18 per cent, 
of the workhouse inmates of this country are feeble-minded. 

Similarly with those in receipt of outdoor relief : most of them 
are young adults, and although a percentage are doing work 
which contributes to their support, there is no doubt that under 
a proper system they might be employed to much greater advan- 
tage. Less than one-fourth of those in Manchester were usefully 
employed ; in the country districts, however, where work of a 



284 Mental Deficiency 

character more suited to the capacity of these persons is available, 
from one-half to two-thirds manage to earn a little. The weekly 
allowance which these defectives receive from the parish varies 
very greatly in the different unions ; on the average it is probably 
about two shillings or half a crown, and with this and the shilling 
or so they earn, supplemented by an occasional gift of boots or 
cast-off clothes, they manage to exist tolerably well as long as 
they have some one to provide them with shelter, and generally 
take care of them. When their protectors die, the refuge of all 
these persons will be the workhouse. 

The fact that 10 per cent, of feeble-minded persons are resident 
in lunatic asylums is an indication of the mental instability, as 
well as deficiency, of this class. For the incarceration of practi- 
cally all of them is due to insanity or epilepsy. 

It is apparent from these inquiries, that not only do a larger 
proportion of town than country defectives receive Poor-Law relief, 
but that both absolutely and relatively far more are relieved in 
the House. It is to be remembered that these remarks relate to 
the feeble-minded degree of defect only, a class which is defined 
as being " capable of earning a living under favourable circum- 
stances." The facts are sufficient evidence as to how little favour- 
able the actual circumstances at present are, and it may be re- 
marked that not a few of these feeble-minded paupers have been 
educated at great cost in special schools. How illogical is the 
system which spends thousands upon the training of mentally 
defective children, and then turns them adrift to shift for them- 
selves as best they can ! 

Idiots and Imbeciles. — Of the idiots and imbeciles about 54 per 
cent, are paupers, of whom about two-thirds are in institutions, 
and one-third in receipt of outdoor relief. Of those in institu- 
tions, nearly two -thirds are in idiot or lunatic asylums, and the 
remainder in the workhouse. There is no doubt, however, that a 
considerable number of the imbeciles at present attending ele- 
mentary schools (where they learn nothing, and are often a con- 
siderable annoyance and distraction to teachers and scholars 
alike) will eventually become a charge upon the rates, whilst a 
large proportion of those not at present in receipt of relief will 
need provision upon the death of their parents. 

With regard to the granting of relief to idiots and imbeciles, it is 



The Ament and Society — Pauper Aments 285 

interesting to notice the difference of method between town and 
country districts respectively. The proportion actually relieved 
in the two situations is pretty much the same ; but whereas in the 
towns 36 per cent, are in the workhouse and 7 per cent, outside, 
in the country there are but 14 per cent, in the house, as against 
32 per cent, receiving outdoor relief. 

Vagrancy. — We may now consider this question. Many feeble- 
minded persons, with a home to which they can turn, have such 
a propensity for wandering that they will roam the country for 
miles round, and sometimes be away for days together. These are 
often well known to all the country-side, and they frequently get 
a plate of food and a shakedown in the barn of some hospitable 
farmer ; failing that, they spend the night in a dry ditch. I do 
not think they ever have any definite objective ; they simply 
ramble on where the fit takes them. I remember once pursuing 
one of these youths, whom I particularly wanted to find, for a 
whole day. I got scent of him from time to time, but, although I 
was driving and he was on foot, it was nightfall before I overtook 
him, and he must have walked at least twenty miles. 

On the other hand, a small number have no permanent home, 
but simply shift for themselves as best they may, and these, 
perhaps, are more properly called vagrants. As a rule, they are the 
least defective members of the feeble-minded, and although the 
bulk of them drift into the workhouse sooner or later, they do for 
a time, particularly in the country, manage to exist by their wits. 
How this is accomplished can generally only be conjectured ; 
many of them seem to be itinerant vendors of something or other, 
and no doubt they often get a free meal or cast-off suit of clothes 
given to them, failing which they are not averse to begging. 
Some years ago I used constantly to meet a feeble-minded couple 
of this description — man and wife — who roamed the country col- 
lecting rags, bones, rabbit-skins, and such-like. But my inquiries 
showed that their defect gave them an unfair advantage over 
their normal-w T itted competitors, inasmuch as compassion gained 
for them what money had to procure for the others, and this is 
probably the case with most of the feeble-minded living by their 
wits. A few of these persons manage to earn enough to pay for 
bed and breakfast in a common lodging-house ; these, however, 
are the elite, and the majority either sleep " rough " or get a bed 



286 



Mental Deficiency 



in the casual ward. The inquiries of the Royal Commission show 
that on the whole about 10 per cent, of the feeble-minded come 
within the category of vagrants, whilst about 10 per cent, of all 
vagrants are feeble-minded. For the most part I think they are 
well-behaved and inoffensive, but some have decided insane or 
criminal tendencies and such are an undoubted menace to society. 
I have already remarked that competition is much more adverse 
to the feeble-minded in the towns than in the country, and that 
in consequence a larger proportion of them gravitate into institu- 
tions. This is well shown by the following table which I have 
compiled from the Royal Commission Reports : 



TABLE XVI. 

Showing the Location of Feeble-minded in Urban and Rural 
Areas Respectively. 





In 

Institutions 
(Paupers). 


In Receipt of 
Outdoor 
Relief. 


Not at Prese 
Rel 

Relief will 

probably be 

required 

upon Death of 

Friends. 


nt receiving 
ief. 

Friends capable 

of making 
Permanent Pro- 
vision.* 


Urban and industrial 
areas 

Rural areas 


Per Cent. 
762 


Per Cent. 
27 


Per Cent. 

ig-2 

398 


Per Cent. 
17 

136 


79-0 
257 207 

46-4 



Aments under Inadequate Care. 

By no means one of the least important of the facts ascer- 
tained by the Royal Commission is the number of aments, in the 
eleven areas examined, whose care and control is inadequate, 
and for whom further provision is needed, either (1) in the 
interests of the patients themselves, or (2) for the public safety. 
The former group consists of persons who, in the opinion of the 
respective investigators, are unsuitably or unkindly cared for ; 

* Owing to difficulty of investigation, this class is probably understated. 



The Ament and Society — Pauper Aments 287 

the latter, of aments possessing habits and propensities which 
render them a source of danger to the community in which 
they live. It was recognized that many persons might be living 
under conditions which were not ideal, but these are not in- 
cluded, the object being to ascertain the irreducible minimum in 
urgent need of provision at the present time. I propose to quote 
these figures as affording statistical proof of the extremely un- 
satisfactory relationship at present existing between the ament 
and society. 

In column 2 of the following table is shown the percentage of 
persons suffering from each of the three degrees of defect who 
were found to be inadequately cared for in the areas examined. 
There is no reason for thinking that these results are other than 
typical of the entire country ; column 3 therefore shows the 
estimated total number of these persons in England and Wales.* 



TABLE XVII. 

Aments Inadequately Cared for. 



Degree of Defect. 


Percentage inadequately 

caved for to Total 

Number in Eleven 

Areas investigated by 

Royal Commission. 


Estimated Total 
Number inadequately 

cared for in 
England and Wales. 


Idiots 

Imbeciles 

Feeble-minded persons 


40 8 per cent. 
46*2 ,, 
318 „ 


2,3«I 

7.689 
15.793 



It is of interest to note the chief locations of these persons 
needing further provision. In the case of the feeble-minded, the 
highest proportion of those unsatisfactorily provided for occurs 
in the classes at large and in charitable institutions, in which 
situations between 40 and 50 per cent, require further care. 
With regard to those at large this high proportion is not sur- 
prising, but a word of explanation is necessary in the case of the 

* This estimate is calculated from the total number of aments existing 
in the country, as ascertained by the method described in Appendix II., 
p. 366. It does not include Feeble-Minded ("Mentally Deficient") 
Children, who, according to the Report of the Royal Commission, number 
35,662, or 0*59 per cent, of the children on the school register. 



288 Mental Deficiency 

charitable homes. The high proportion here is not any reflection 
upon these homes, but is simply due to the fact that their provision 
is temporary and optional only, and that most of the inmates 
are feeble-minded girls who have given birth to children. It is 
obvious that in the case of such persons detention should be 
permanent and compulsory. About one-fifth of the feeble-minded 
in workhouses, and one-fourth of those in receipt of outdoor relief, 
are reported to be unsatisfactorily provided for. 

Of the idiots and imbeciles, the greatest proportion in need of 
provision occurs amongst those receiving outdoor relief. In 
two-thirds of these the present conditions are so unsatisfactory 
as to urgently call for amendment, and nearly all of these are in 
rural districts. Of those at large in fairly well-to-do circumstances, 
one -quarter require further care or control ; whilst of those at 
large who are the offspring of the labouring class, the present 
provision is unsatisfactory in one-half. There can be no doubt 
that the presence of these persons in small and often overcrowded 
cottages is fraught with considerable possibilities of harm. But 
even apart from actual danger, want of time and want of know- 
ledge on the part of the parents must prevent the imbecile or 
idiot receiving the attention he needs, and which he would obtain 
in an institution ; whilst his presence cannot be regarded as con- 
ducive to the comfort of the home. As far as the idiots and 
imbeciles themselves are concerned, the accommodation provided 
by the workhouses is tolerably satisfactory ; it is rarely, however, 
that any special wards exist for them, and it must be admitted 
that the other inmates often view the question in a somewhat 
different light. 

Propagation by Aments. 

There is no law in this country to prevent the marriage of the 
mentally defective, and every one knows that they do marry and 
have children. It is also equally well known that mentally 
deficient women not infrequently give birth to illegitimate 
children ; but, as far as I am aware, until recent years there has 
been little definite inquiry made into this subject, and no sufficient 
data upon which to form any opinion as to the frequency of this 
evil. Some particulars ascertained by the investigations of the 
Royal Commission now throw a lurid glare upon the subject. 



The Ament and Society — Pauper Aments 289 

They relate entirely to feeble-minded females, and chiefly to 
inmates of workhouse maternity wards. 

In Manchester, Dr. Melland found that, out of 94 women in these 
wards, 19 were feeble-minded, all the children except two being 
illegitimate. On making further inquiries of some of the younger 
of the other 167 feeble-minded women in the house, it was ascer- 
tained that another 13 admitted having given birth to illegitimate 
children, and Dr. Melland states that these inquiries were only of 
a partial and incomplete nature. 

In Birmingham, Dr. Potts found that 4 out of the 34 women in 
the maternity wards were mentally defective, whilst at Stoke-on- 
Trent the same observer found that, of the 17 women giving birth 
to children during the period of inquiry, 7 were feeble-minded, all 
the children being illegitimate. Dr. Potts ascertained that the 
total progeny resulting from 16 mentally defective women was no 
less than 116. In the lock wards he found 5 feeble-minded women, 
all of whom were prostitutes. 

In the rural districts the state of affairs was even worse. In 
Wiltshire, Dr. Pearse found that, of 58 feeble-minded women in 
the workhouse, 18 had given birth to illegitimate children. 
In Nottinghamshire, Dr. Gill ascertained that n out of 23 of 
these women had borne illegitimate children. In Carnarvon, 
Dr. Parry found that half the inmates of the maternity wards 
were mentally defective, nearly all the children being illegitimate ; 
whilst in Somersetshire I ascertained that fully half of the women 
admitted into the workhouse to be confined during the previous 
five years had been feeble-minded ; further, that out of all the 
feeble-minded women in the area (167), nearly two-fifths (61) had 
given birth to children, two-thirds of whom were illegitimate. 

In few cases is the propagation by these women limited to a 
single child. More often their offspring number three or four, 
and one woman had given birth to six illegitimate children. All 
of these were by different fathers, and she was confined of each 
one in the workhouse. I may add that I discovered one feeble- 
minded woman in a workhouse who had given birth to four 
illegitimate children, although she had never left the precincts of 
the house. 

When it is remembered that these figures only relate to a rela- 
tively small portion of the country, and that the investigations 

19 



290 Mental Deficiency 

only extended over a period of about three months, it is clear that 
the number of children produced every year throughout England 
and Wales by feeble-minded women must be very great. In some 
cases the mothers have pronounced erotic tendencies, and many 
of them seem to be utterly lacking in any sense of shame, modesty, 
or even ordinary decency ; but even the best-behaved, and those 
of good parentage brought up amid every refinement, are often so 
facile that it is utterly unsafe for them to be at large without 
protection. 

To the above may be added a statement by Dr. Ireland, to the 
effect that the Scottish Lunacy Commissioners in their Report for 
the year 1857, " ascertained that the number of idiotic women who 
have borne illegitimate children, and whose mental defect is fre- 
quently manifested in their offspring, was no less than 126, and the 
return was not believed to be complete. Among the paupers in the 
parish of Kintore there was a fatuous mother with her two fatuous 
children. In the parish of Latheron, in Caithness, five imbecile 
females were named as having become mothers. The largest 
number of children anywhere returned to one fatuous female was 
five, the mother being an idiot belonging to the parish of Erskine, 
in Renfrewshire." 

As bearing on the same question, I may cite some returns 
obtained by the Preventive Committee of the National Vigilance 
Society. As a result of special inquiries of 203 Boards of 
Guardians, it was found that, during the year 1889, 715 weak- 
minded women passed through 105 workhouses, whilst at 56 
workhouses it was stated that the approximate number of such 
women who were leading immoral lives was 366. . 

With regard to the children of these mentally deficient women, 
it would, of course, be of the greatest interest and importance 
to know what becomes of them. Unfortunately, particulars of 
this kind are very difficult to obtain, and definite information 
is in consequence very scanty. I may state the following facts 
which were ascertained by myself : Of the 61 feeble-minded 
mothers whom I saw in Somersetshire, 19 were married and 42 
unmarried. The 19 married have produced a total of 80 children. 
Of these, 16 died in infancy, 19 are imbecile or feeble-minded, 
20 are either physically delicate to a pronounced degree or are 
mentally dull and backward, whilst 8 are too young to satis- 



The Ament and Society — Pauper Aments 291 

factorily examine. There are only 17 out of the total 80 who 
appear to come up to the average standard of mental and bodily 
health. With regard to the illegitimate children, the particulars 
are of necessity less complete. The 42 mothers have produced j8 
children. Of these, 24 died in infancy, 5 are imbecile or feeble- 
minded, 2 are markedly dull and backward, 2 appear to be 
normal, and the remaining 45 have been completely lost sight of. 
It must be remembered that in practically all these cases infor- 
mation as to the paternal inheritance of these children is un- 
obtainable. 

As bearing upon the questions of propagations and the social 
relationship of the ament, I may cite the following cases which 
have recently come within my experience : 

Upon the edge of a moor, in a thinly inhabited part of the 
West Country, stands a filthy thatched wooden hovel consisting 
of two rooms. Its exterior has an air of utter desolation and 
neglect ; its interior is in a state of indescribable dirt and con- 
fusion. It is occupied by a married couple and their family. The 
man, aged fifty years, is of a decidedly low animal type, and has 
considerable moral, as well as slight mental, defect. He never 
refuses a drink, and picks up a living by occasional osier-stripping, 
and doing odd jobs on farms, but chiefly, I think, by poaching. 
The woman, his wife, is forty-four years of age and feeble- 
minded. She seems to be busy most of the day, and in her way 
keeps the house going ; but she is utterly lacking in any capacity 
for management, and the filth and disorder are extreme. This 
woman had three children before marriage, and nine since. Of the 
former three, one died young of consumption, a second has 
entirely disappeared, and the third lives about the neighbourhood ; 
but he quarrelled with his mother's husband, and they are not 
now on speaking terms. Of the nine born in wedlock, two died in 
infancy, three attend the village school and are mentally defective, 
and another also mentally defective is at home. The eldest does 
odd jobs with his father, and seems to be able to take care of 
himself. The remaining two are aged five months and three years 
respectively, and are too young to enable an opinion to be formed 
as to their mental capacity. To this it may be added that the 
father has had ten children by a previous wife. Of these, two are 
feeble-minded, one of whom is living a life of prostitution, and 

19 — 2 






292 Mental Deficiency 

has already had two illegitimate children in the workhouse. The 
others have been entirely lost sight of. 

Mary H is a feeble-minded married woman forty years old. 

She lives with her husband, a farm labourer, in a small cottage in 
an isolated village. She is industrious and always working, 
but the house is in a disgraceful muddle. At my visit there 
were two unwashed, partially dressed children, under three years 
of age, sprawling about the wet stone floor amid a litter of dirty 
plates and pans, potato peelings, and live poultry. Upon asking 
her how old she was, and how long she had been married, she 
replied, with a fatuous smile, that she didn't know, but her 
mother did. The children I saw in the house were too young to 
examine mentally ; but two other illegitimate children whom I 
did see, aged sixteen and seventeen years respectively, were 
feeble-minded. Both of these are industrious boys, and work well 
under supervision, but they are quite incapable of looking after 
their affairs. This woman has two brothers, who are also feeble- 
minded ; one is constantly in and out of the workhouse, but the 
other, aged thirty, is employed regularly with a farmer at the 
rate of a shilling a day. Their mother has had several attacks of 
insanity, but the father is dead, and no particulars were obtain- 
able regarding him. 

Rose D is a feeble-minded woman forty-five years of age. 

She is the daughter a of well-to-do farmer, but ran away from 
home at the age of twenty years, and since then she has been 
living a life of prostitution. Her usual abode is the common 
lodging-house, but a considerable part of her life has been spent 
in prison, the workhouse, and various charitable homes. She has 
been confined of three illegitimate children in the workhouse. 
The clergyman of the parish in which she lives says that he has 
got her into homes again and again, but she will not stay, and 
they cannot compel her to do so. All attempts to induce her 
to lead a respectable life have failed, and she is his despair and 
a disgrace to the civilization which permits her to be at large. 

I may add that these are by no means isolated instances. 
Many of the particulars regarding this matter which have come 
under my own notice are too revolting for publication, and there 
is the clearest evidence that the propagation by aments is both 
a terrible and extensive evil. 



CHAPTER XVI 

MORAL DEFICIENCY AND CRIMINAL AMENTS 

The subject of moral deficiency is one of extreme interest alike 
to the alienist and criminologist, and although some persons 
would be inclined to look upon the moral or ethical sense as 
transcending mind altogether, it is, nevertheless, so clearly an 
integral part of that complex sum of processes to which we give 
the name mind that the question of moral deficiency cannot be 
ignored in a work dealing with amentia. 

But although the moral sense is unquestionably part of the 
tout ensemble of mind, it does not follow that the person in whom 
it is defective is necessarily an ament. There are four chief 
" senses " or " sentiments " which, in varying proportions, go 
to make up the mind of average civilized man. These may be 
described as the logical or intellectual, the religious, the aesthetic^ 
and the moral or social. The logical or intellectual sense 
causes us to test each new experience by the light of our previous 
knowledge, to criticize and carefully compare, and to accept or 
reject according as our judgment affirms it to be true or untrue. 
Such a type of mind is said to be essentially rational. The 
religious sense implies a conception of the relationship between 
God and man. It is largely made up of the emotions of awe, 
reverence, and adoration, and religion has been well defined 
as " The feeling of reverence which men entertain toward a 
Supreme Being, or to any order of beings conceived by them 
as demanding reverence from the possession of superhuman 
control over the destiny of man or the powers of nature."* The 
aesthetic sense connotes a marked appreciation of all that is 
beautiful in form, colour, sound, etc. Whilst, lastly, by the 
* Ogilvie and Annandale, " Imperial Dictionary." 
2 93 



294 Mental Deficiency 

moral sense is meant the faculty of appreciating the obligations 
due from man to his neighbours as component units of society. 

Now, these various senses are differently developed in different 
individuals, and this is partly a result of special hereditary 
tendencies, and partly due to the nature of the early environment. 
Some persons are full of religious and moral feeling (although 
the two are by no means synonymous), and yet absolutely 
illogical and inartistic. Others, of extreme aesthetic develop- 
ment, have no sense of logic ; whilst yet others, of the keenest 
intellect and highest logical capacity, are devoid of moral con- 
sciousness. The mind of the child is usually deficient in this 
latter sense, and it is only by the constant force of example, the 
reiteration of precept, and perhaps the infliction of punishment, 
that it learns to think and act according to the stereotyped social 
and legal code of the age to which it belongs, and so conforms 
to moral and social law. 

Although human conceptions of morality, as also of religion 
and art, are ever changing with social development and the 
progressive evolution of the mental faculties, there is every 
reason for thinking that some persons are so constituted that 
they are utterly devoid of any real moral sense, and of the 
consciousness that any obligation is morally due from them to 
their fellows ; just as others may have no sense of religion or 
no conception of the beauties of form, colour, or sound. Such 
defect is inherent, and it may rightly be called moral deficiency. 

Its relation to criminality, however, is another matter. It 
may be that, although these persons have no feelings of repug- 
nance or shame at the thought of a criminal or immoral act, and 
although they cannot appreciate the ethics of the Decalogue, 
nevertheless their intelligence tells them that certain unpleasant 
consequences, in the shape of judicial punishment or social 
censure, will follow transgression, and this suffices to keep them 
within the prescribed legal and social code. Their moral defect 
is, in fact, latent. 

It is the same with the aesthetic and religious senses. " Many 
persons utterly devoid of conceptions of beauty or harmony 
still manage to avoid running counter to the canons of good 
taste by conforming to the recognized customs of society, and 
how many who are absolutely wanting in any real religious feeling 



Moral Deficiency and Criminal Aments 295 

acquire a reputation for piety and reverence as a result of their 
scrupulous observance of religious form and ceremony ! 

But although latent moral defectives of this kind are not of 
necessity actual criminals, they may well be described as potential 
criminals. They stand in the same relation to the inmates of our 
prisons as do the psychopaths or potential lunatics to the inmates 
of our asylums, or the improvident to the inmates of our work- 
houses, and there can be no doubt that it is from this class that 
one section of our criminals is drawn. Although there is no 
intellectual defect, and such persons fully realize the conse- 
quences of detection, yet occasionally the gain resulting from a 
crime or act of immorality appears so great, and the likelihood 
of discovery so small, that, moral sense being absent, they deliber- 
ately take the risk. Since, however, our standard of mind is an 
intellectual one, such persons can no more be considered as 
mentally deficient than can those who are lacking in the religious 
or aesthetic sense. 

But the case is different with another class. There are some 
persons, likewise deficient in moral sense, who repeatedly commit 
criminal acts, and upon whom punishment has not the slightest 
deterrent effect whatever. These form a large proportion of 
the instinctive or habitual criminal class, the true moral defec- 
tives, and they may be defined as " those persons who display 
from an early age, and in spite of careful upbringing, strong 
vicious or criminal propensities on which punishment has little 
or no deterrent effect." 

As to whether the members of this class are or are not intel- 
lectually deficient, opinions differ. It it contended by some that 
such a propensity to crime may exist without any intellectual 
defect, whilst others maintain that a deficiency of the intellectual 
faculty is also present — that, in fact, such persons are aments. 
The question is one which it is extremely difficult to decide. On 
the one hand there is no doubt that, although many of these 
persons commit offences in the most open manner, and from 
which they have nothing to gain, yet they will converse upon 
many subjects in an exceedingly intelligent way, whilst some 
are actually possessed of unusual talents. A few again, in their 
commission of offences and their attempts to escape detection, 
show a capacity, alertness, and cunning, of a very high order, and 



296 Mental Deficiency 

which also would seem to be incompatible with the presence 
of amentia. On the other hand, however, their utter inability 
to keep within the law and to control their evil propensities, 
when they know that punishment has followed, and will almost 
inevitably follow again, is certainly suggestive of a deficiency of 
intellect, or, at any rate, of a defective power of self-control. 

As tending to elucidate this question, we may refer to the 
many characteristics which these persons possess in common 
with aments. During recent years numerous investigations have 
been carried out in England, America, Italy, France, Germany, 
and Russia with regard to the physical and psychological features 
of the habitual or instinctive criminal class, and of which many 
particulars are given in Havelock Ellis's most interesting book 
" The Criminal." To some of these we may refer. 

With regard to the brain, the results do not enable one to 
say that a special " criminal type " exists, but nearly all the 
inquirers are agreed that anatomical anomalies indicative of 
arrested development are of much more common occurrence 
than in the normal population. The same is true of the face, 
jaws, palate, and body generally ; in the habitual criminal 
stigmata of degeneracy abound just as they do in the ament. 
The Anthropometric Committee of the British Association 
examined over 3,000 criminals, and found them about 2 inches 
shorter and 17 pounds lighter than the average English population. 
Baer examined 4,500 Berlin criminals, and found that the average 
height was decidedly below the normal, and the same was 
observed by Hamilton Wey in America. Dr. G. Wilson, in a 
paper on " The Moral Imbecility of Habitual Criminals as 
Exemplified by Cranial Measurements,"* arrived at the conclu- 
sion, from measurements of the heads of 464 criminals, that 
habitual thieves had well-marked indications of defective, cranial 
development associated with physical deterioration. Dr. J. 
Bruce Thompson, f in a summary of his observations upon over 
5,000 prisoners, pointed out the great prevalence of mental 
defect, especially amongst the juvenile criminals, and also the 
frequency with which morbid appearances were found post- 
mortem. Professor Lombroso, in his book " L' Uomo Delin- 

* A paper read before the British Association at Exeter, 1869. 
f Journal of Mental Science, 1870. 



Plate XXVI. 





> 


' 






r^^^ 


a 


:! 


'^ 




y^A 




To face pa^e 296.' 



Moral Deficiency and Criminal Aments 297 

quente," came to the conclusion, on anthropometrical grounds, 
that the criminal is a manifestation of degeneracy. 

Similarly with mental characteristics. Although many of the 
criminal class appear on casual examination to be of average 
intellectual calibre, there is abundant evidence to show that a 
large number of them present anomalies similar to those referred 
to in our description of the Feeble Mind. As Havelock Ellis 
says, " On the one hand he is stupid, inexact, lacking in fore- 
thought, astoundingly imprudent ; on the other hand he is cun- 
ning, hypocritical, delighting in falsehood, even for its own 
sake, abounding in ruses." And in another place, " The criminal 
in some of his most characteristic manifestations is a congenitally 
weak-minded person, whose abnormality, whilst by no means 
leaving the mental aptitudes absolutely unimpaired, chiefly 
affects the feelings and volition, so influencing conduct and 
rendering him an anti-social element in society." Dr. Maudsley,* 
speaking of instinctive criminals, says : " It is a matter of observa- 
tion that the criminal class constitutes a degenerate or morbid 
variety of mankind marked by peculiarly low physical and 
mental characteristics ;" whilst Dr. Nicholson f has also pointed 
out the great prevalence of weak-mindedness, with instability, 
tendency to delusions, insensibility, and emotional nature, in the 
criminal class. 

Finally, the close connexion between criminals and aments 
is further shown by the antecedents of the two classes. In 
inquiring into the family histories of members of the habitual crim- 
inal class, I have often been struck by the fact that, although 
they themselves might show little obvious indication of mental 
inferiority, a large number of them came of a neuropathic stock, 
and possessed brothers and sisters who were markedly deficient. 
Conversely, in examining aments, I have often found that their 
brothers or sisters were criminals. In dealing with the inmates 
of prisons it is often extremely difficult to obtain a family history, 
but it was ascertained that, of 233 prisoners at Auburn, New 
York, at least 23 per cent, were of neurotic (insane and epileptic) 
origin. Rossi found that in 71 criminals there were 5 insane 
parents, 6 insane brothers and sisters, and 14 cases of insanity 

* Maudsley, " Responsibility in Mental Disease," 1872. 
f Nicholson, Journal of Mental Science, 1873-1875. 



298 Mental Deficiency 

amongst more distant relatives. Kolk found a morbid inheritance 
in 46 per cent, of criminals, and Marro in yy per cent. Sichard, 
as a result of his examination of nearly 4,000 German criminals, 
found that there was an insane, epileptic, suicidal, or alcoholic 
heredity in 36*8 per cent, of incendiaries, 32 per cent, of thieves, 
28*7 per cent, of sexual offenders, and 23*6 per cent, of sharpers. 

Lastly, the interesting record of the Juke family, which was 
compiled by R. L. Dugdale,* well shows the close relationship 
existing between the criminal and the psychopath. This observer 
traced the descendants of one morbid couple through five genera- 
tions to the number of 709 individuals, and found that whilst a 
small proportion were honest workers, the great majority were 
vagabonds, paupers, criminals, and prostitutes. 

I think these facts (and I have only referred to a few of them) 
conclusively show that, although in a large number of habitual 
or instinctive criminals the defect may appear to be more moral 
than intellectual, nevertheless their persistent criminality in 
spite of punishment, as well as the many features they possess 
in common with the true aments, are a sufficient justification for 
our considering them as being closely related to, if not actually 
suffering from, a mild degree of mental deficiency. 



Criminal Aments. 

We may now consider a somewhat different class, namely, 
persons suffering from undoubted intellectual deficiency who 
have pronounced immoral and criminal tendencies, and who are 
in consequence guilty of repeated offences against law and society. 

Such persons may belong to any of the three degrees of 
amentia. As we have seen, idiots are often extremely destruc- 
tive, and they may commit homicide. Many imbeciles have 
pronounced thieving propensities, are guilty of incendiarism, or 
possess marked sexual desires, which they may forcibly seek to 
gratify. More commonly, however, criminal aments belong to 
the feeble-minded or mildest degree, and this is probably the 
result of their greater personal freedom from supervision, as well 
as their numerical preponderance — perhaps, also, partly owing 
to their greater knowledge. 

* Putnams, New York, 1877. 



Moral Deficiency and Criminal Aments 299 

Some idea of the number of mentally deficient criminals under 
detention in this country, and of the general policy of the Prison 
Commissioners regarding them, will be gathered from the reply 
to a question in the House of Commons on July 22, 1907. The 
Home Secretary said : "Both in local and convict prisons those 
prisoners who are not certifiably insane, but are unfit through 
mental deficiency for the ordinary penal discipline, form a 
separate class and are specially treated. In the year 1906-07 
the numbers were : the local prisons 355, and in convict prisons 
107. The policy of the Prison Commissioners is to place these 
prisoners under the special charge of the medical officers of the 
prisons, and to keep them continuously under the personal care 
of selected warders. The medical officers regulate their dis- 
cipline and diet, and allow them such employment as is suited 
to the condition of each individual. In addition to those so 
classified, there are other prisoners temporarily under observa- 
tion to ascertain their mental state." 

The recent investigations of the Royal Commission show that 
about 10 per cent, of the inmates of prisons are aments. These 
figures must be considered rather to under-estimate than over- 
estimate the facts, for the uniform practice of the inquirers was to 
include only such cases as showed clear and undoubted signs of 
mental defect. On the other hand, a careful analysis of the 
same inquiries shows that about 10 per cent, of all feeble-minded 
persons have pronounced criminal and antisocial propensities. 

Feeble-minded criminals, using this latter word in its widest 
sense, fall into three groups. On the one hand there are those 
who are led into the commission of offences against law and 
morality by reason of their extremely facile disposition, which 
makes them ready tools in the hands of evil-doers. The deficiency 
here is largely one of control or of knowledge, and they are 
rather sinned against than sinning. Our police-courts show 
that feeble-minded dupes of this kind are by no means unknown 
to-day, although it is likely that the number of persons profiting 
by this failing of the mentally defective has been considerably 
diminished in recent years. At the present time it is probable 
that prostitutes comprise the largest proportion of this type, 
especially in our towns and industrial centres. 

Another group of feeble-minded persons are of such an ex- 



300 Mental Deficiency 

citable, explosive, and generally unstable mental constitution 
as to be utterly untrustworthy, and a considerable number of 
the offences against society are committed by this class. It 
may be termed "the impulsive type of criminal anient." Far 
from being facile, they are generally extremely obstinate and 
intolerant of contradiction, and they will often suddenly pass 
from a state of what appears to be perfect calm and indifference 
to one of raving, uncontrollable fury. Many of them are very 
suspicious, and some have definite delusions ; in fact, I think 
that all this class have an extremely strong tendency to insanity, 
and that often during the commission of their offences they are 
actually insane. Most, but not all, are of the mildest degree 
of amentia. In many of their characteristics these persons 
resemble the epileptics, but I do not think that they commonly 
suffer from epilepsy. The offences most commonly committed 
are criminal and other assaults, acts of wanton destruction, 
cruelty to animals, fighting, brawling and disorderly conduct. 

Feeble-minded persons in general are very intolerant of 
alcohol, but its effects seem to be especially marked upon the 
type we are now considering. I remember one youth in a country 
village who used to be repeatedly plied with cider by the yokels 
of the place in order that they might be amused by his furious 
excitement, pretty much in the same way as a bull is baited in 
the ring. The following are good examples of the type : 

Thomas B , a feeble-minded young man, twenty-five years 

of age, with numerous stigmata of degeneracy. He could never 
learn at school, and afterwards could not keep his situations. 
At the age of twenty-three he became insane, and was sent to 
the asylum for six months. Shortly after discharge he was 
apprehended for sleeping out, and served seven days' imprison- 
ment. He had only been out a few weeks when he attempted 
rape on a small girl whom he met in the road. For this he was 
sentenced to two months' hard labour. On being liberated he 
became very violent and aggressive, and threatened to cut his 
mother's throat. He was again sent to the asylum, and dis- 
charged in six months. He is now living at home, and works 
occasionally in the factory ; but his mother says that he cannot be 
depended upon, that some days he refuses to get out of bed, and 
is at times so violent that she is afraid to have him in the house. 



Moral Deficiency and Criminal Aments 301 

He is a powerful fellow, who should be capable of hard work 
could he be controlled. 

Alfred L , a feeble-minded man of twenty-eight years. He 

is now occupied cracking stones, and does occasional work on 
farms when he can get it ; but he is very unstable, at times being 
noisy, excitable, quarrelsome, and absolutely refusing to do any 
work. He has been imprisoned at least six times for such 
offences as drunkenness, fighting, stealing, and setting fire to gorse, 
and is known and dreaded for miles round as a regular nuisance. 

The third group is, I think, the most numerous of all, and 
consists of those feeble-minded persons who commit crimes, not 
under external suggestion, and not because they are passionate 
and excitable, but because either they cannot really appreciate 
the difference between right and wrong or have ineradicable 
and irresistible criminal propensities. In fact, they suffer, not 
so much from a defect of inhibition, as from a pronounced mental 
and moral perversion. The crimes of these persons differ from 
those of the two preceding groups, inasmuch as, although they 
may at times appear to be sudden and unpremeditated, they 
more often show evidence of previous deliberation and plan, 
and sometimes of considerable cunning to escape detection. In 
addition to persistent lying, thieving, indecency, acts of cruelty 
and wanton destruction, these individuals are often guilty of the 
more serious crimes of incendiarism, train-wrecking, criminal 
and homicidal assaults. 

It is a remarkable fact that, although these persons whilst at 
liberty and away from supervision seem absolutely incapable 
of conforming to the law, they are nearly always quiet and 
well-behaved under the discipline of a prison. Their lives 
consist of an unbroken series of offences, in many cases there 
being literally scores of convictions, whilst in some they amount 
to over a hundred. They are the definitely mentally defective 
habitual criminals. 

In most of these cases the condition is present in childhood, 
and is shown by habits of lying, thieving, and the like, upon 
which punishment has not the slightest effect. I know one boy 
who has not yet reached his eighth birthday, but he has already 
been expelled from school because nothing was safe within his 
reach. He has a vocabulary equal to that of any bargee, and 



302 Mental Deficiency 

he steals eggs, fruit, money, and anything he can lay his hands 
on; he has already burnt two hayricks to the ground. In 
an elementary school of a provincial town I came across three 
children of this type belonging to one family. The two boys were 
only eight and five years old respectively, and the girl seven 
years : but the schoolmaster told me that they had a propensity 
for lying, thieving, and causing trouble generally, the like of 
which he had never met, and that nothing seemed to deter them. 
They were all mentally defective, and I was informed that the 
father was of the same type, and more often in than out of 
prison. The following cases are further examples of this class : 

George P , a mentally defective child, aged thirteen and a 

half years, attending school in Standard I. Power of reasoning 
decidedly wanting, but alert and cunning, and always getting 
into trouble. He is said to be incorrigibly lazy at school, and 
a frequent truant, and the schoolmaster says that he will 
steal and lie without the least compunction, and that punish- 
ment seems to be without the slightest effect. He is always 
ready with a plausible excuse, and shows a precocious amount of 
cunning in covering up his misdeeds. A short time ago he stole 
the schoolmistress's gold watch from its accustomed place on 
her desk. It was not missed until the children had left, and 
then there was an instant hue and cry. George, finding himself 
pursued, secreted the watch in a tree, and then submitted himself 
to be searched with an air of complete innocence. Unluckily, 
however, for him, the manoeuvre had been seen. It is interesting 
to note that this boy's father is just the same (indeed, I am 
inclined to think that this moral perversion is generally heredi- 
tary). He is plausible and cunning, and, although he occasionally 
does odd jobs, I was told by the police that he never did any 
regular work, and that the greater part of his life had been spent 
in prison for such offences as stealing, poaching, and drunken- 
ness. When I saw him he had just returned from serving a 
term of imprisonment for poaching. 

George A , a feeble-minded, undersized youth with a slouch- 
ing walk, furtive demeanour, and physiognomy typical of mental 
defect. He answers questions in a simple, childish manner, 
and gives information regarding his past life willingly and with- 
out any appearance of shame or concern ; his memory, however, 



Moral Deficiency and Criminal Aments 303 

is a little defective, and his account is at times confused and 
incoherent. He cannot read, write, or sum, but he is quite 
capable of useful work under supervision, and his conduct in 
prison (where I saw him) is good. The youth knows nothing 
about his parents, and little about his early life beyond the fact 
that he was brought up in an industrial school, and thence put 
to work on a farm. He ran away because he wanted a change, 
and, after tramping about for a time, eventually got employment 
on another farm. He ran away from here because he was 
discovered committing acts of indecency with the cattle. He 
then tramped about, and was frequently in and out of work- 
houses. He was convicted with several others of stealing lead, 
and served a term of imprisonment. After this he again tramped 
the country, spending most of his time between the prison and 
the workhouse. He is now in for setting fire to a rick, for 
which act he is unable to give any reason. 

Finally, as further examples, I may refer to the following four 
cases culled from the newspapers during the past few months, 
all of which were reported to be mentally defective. 

" W. K., a ten-year-old boy, was charged at Bow Street with 
attempted pocket-picking in a rail way- train. The boy excused 
himself by saying that his mother had pushed him into the 
train with orders to rob the lady. The police found that there 
was not a tittle of evidence to support the lad's statement, 
and an officer from the school board reported that he was 
mentally defective." 

"H. A., a. feeble-minded deaf-mute, was charged with stabbing 
his sister. The prosecutrix said that he had never been quite 
right in his mind, and that she had always treated him as a child, 
but that he was no trouble if he did not get into drink. The 
medical officer of the prison certified him as being of weak 
mind and likely to be easily affected by drink, but he could not 
certify him as insane. The charge was reduced to one of common 
assault, and the magistrate thought it would be good for the 
youth to go to prison, and committed him for two months." 

" G. E. R., aged nineteen, was indicted for endangering the 
safety of persons being conveyed upon the London and North- 
western Railway by placing a coil of disused electric wire on the 
line in such a position as to be in the way of any passing trains. 



304 Mental Deficiency 

Prisoner was a typewriter and shorthand clerk, and no motive 
could be assigned for his act. He was admittedly weak-minded, 
but beyond that the medical officers who had had him under 
observation could not go. He was convicted of misdemeanour 
only, and sentenced to pay a fine of £50, or in default to undergo 
six months' imprisonment ; also to find two sureties in £50 
each to keep the peace for twelve months, or go to prison for 
six months in default." 

" T. P. — Owing to the extraordinary series of grave outrages 
committed in Nottinghamshire and the immediate district during 
the past month, much importance was attached to a case which 
occupied the attention of the Mansfield Bench. The man in 
custody, a labourer named T. P., aged twenty-three, a deaf-mute 
of weak intellect, was charged with feloniously placing a wooden 
gate on the Great Central line at Kirkby-in-Ashfield. P. has 
been in the habit of sleeping out, although his reputed place of 
abode is at Sutton-in- Ashfield, within which area there have been 
a number of abortive attempts at train-wrecking. In addition, 
the neighbouring parish churches of Kirkby and Annesley have 
been destroyed by fire upon successive nights, both disasters 
being the work of an incendiary. Prisoner was apprehended in 
a shed at some brickworks. He showed the police-officers a 
spot on the railway where he said he placed a wooden gate on 
the rails. Dr. Gray, who had examined prisoner, gave evidence 
that P. was a lunatic and a proper person to be taken charge of. 
Deputy-Chief-Constable Harrop said, as accused was certified 
insane, no evidence would be offered. The man was first arrested 
in connexion with a robbery at Ulfreton Railway-station, and 
the proceeds were found in his possession ; other robberies on 
the railway had been also traced to him. Prisoner took witness 
and Police-Constable Fryer to Suxton-in-Ashfield, and across 
some fields to the Great Central Railway at Kirkby, where he 
pointed out the exact spot at which an obstruction had been 
placed on the line. He exhibited great satisfaction when a 
train approached, and showed where he had obtained the gate 
and had hidden himself until a train dashed into the obstruction. 
Afterwards prisoner showed exactly where two pairs of trolly 
wheels and a wheelbarrow attached had been placed on the line. 
Accused was ordered to be sent to a lunatic asvlum." 



Moral Deficiency and Criminal Aments 305 



Criminal Responsibility of Aments. 

The law of England recognizes that persons suffering from 
certain forms of mental disease cannot be held accountable for 
their actions, and, generally speaking, this is the case with 
idiots and pronounced imbeciles, or any person who, in the words 
of Mr. Justice Tracey (1723), knows what he is doing " no more 
than an infant, a brute, or a wild beast." With regard to the 
milder degrees of defect, however, the mere presence of feeble- 
mindedness does not of necessity absolve a person from the 
consequences of his acts, and the criminal responsibility of such 
persons, as well as of the insane, is by no means clearly defined. 
There are certain precedents and rulings which are usually 
followed in such cases, but in any particular instance the fact 
of the responsibility or otherwise of the accused is a question 
for the jury to decide upon the evidence presented to them. 
Criminal offences in which this question of responsibility is 
raised are exceedingly common, and it is plainly the duty of 
the members of our profession, who alone can form a correct 
estimate as to the extent to which conduct is likely to be 
influenced by mental deficiency or disease, to formulate general 
principles, and to give their opinion regarding the mental con- 
dition of any particular accused person in order that the jury 
may arrive at this decision. These general principles, however, 
must be just, and whilst protecting those who are really ir- 
responsible from undeserved punishment, they must also protect 
society against the escape from punishment of those who, even 
if mentally deficient, are rightly accountable for their actions. 

The rulings of English Courts at the present time are generally 
based upon the replies of the fifteen Judges to the House of Lords 
in the middle of the last century. Briefly, it may be stated that 
for an accused person to be held irresponsible on the ground of 
insanity, it must be shown that he was of diseased mind, and 
that at the time he committed the act he was not conscious of 
right or wrong, or was under some delusion which made him 
regard the act as right. 

This dictum, it will be observed, takes no account of the 
question of defective control, an omission which was pointed out 

20 



306 Mental Deficiency 

in the exhaustive treatise of Sir Fitzjames Stephen. According 
to this eminent jurist, " No act is a crime if the person who does 
it is, at the time when it is done, prevented from controlling his 
own conduct, unless the absence of the power of control has been 
produced by his own default." I do not propose to enter into 
any discussion regarding the diminution of the will in ordinary 
persons or even in insanity ; but I am quite certain that in persons 
suffering from amentia a diminished power of control is so com- 
monly present, and such an essential part of their mental con- 
dition, that a grave injustice may be done if this be not taken 
into account. There may be non-defective persons who, whilst 
fully appreciating the nature and consequences of certain criminal 
acts, are yet incapable of refraining from committing them, and 
such cases are described as impulsive insanity. But it cannot 
be doubted that there are aments who suffer from a definite 
defect of control which leads them to commit criminal acts. I 
would therefore say that, whilst the mentally deficient person 
is not necessarily irresponsible for any crime he may commit, 
he should certainly be held unaccountable when he commits an 
act (i) of which he does not understand the nature or that it 
is contrary to law ; (2) which is the result of an impulse he was 
unable to control ; (3) which is the natural result of a delusion of 
which he is shown to be the subject. 

With regard to these particular qualifying conditions a few 
words may be said. (1) Want of knowledge as to the nature 
or illegality of the act would usually be capable of ready demon- 
stration in the case of idiots and imbeciles ; but even in the 
milder grades defective intelligence or education might still 
result in ignorance as to how wrong the act was or that it was 
forbidden by law. As was ably pointed out by Sir Fitzjames 
Stephen : " Knowledge has its degrees like everything else, 
and implies something more real and more closely connected 
with conduct than the half knowledge retained in dreams." As 
an instance this author quotes the extreme case of the idiot who 
cut off the head of a man whom he found asleep, remarking that 
it would be great fun to see him look for it when he woke ; and 
he adds : " Nothing is more probable than that the idiot would 
know that people in authority would not approve of this, that 
it was wrong in the sense in which it is wrong in a child not to 



Moral Deficiency and Criminal Aments 307 

learn its lesson, and he obviously knew that it was a mischievous 
trick." And it cannot be doubted that the same kind of in- 
complete knowledge as to how wrong an act is exists in the case 
of many persons suffering from a mild degree of mental deficiency. 
The high grade ament at Earlswood asylum, who has been men- 
tioned as attempting the destruction of an official who had 
displeased him, undoubtedly knew that in so doing he was doing 
what was wrong, but I do not for one moment think that he 
appreciated how wrong his act was, or that, had it succeeded, 
he could justly have been held fully accountable for it. Dr. 
Mercier,* commenting on this question in his recent philosophical 
treatise, says : " It is a truth on which I have insisted in season 
and out of season for many years, that a man may know that 
his act is wrong without knowing how wrong it is." 

(2) Pronounced defect of control in aments is usually clearly 
evident from infancy, although in some cases it may not attract 
attention until puberty. It is one of the chief characteristics 
of the " facile " and " impulsive " types of amentia, and of some 
of the epileptics. It is also a prominent feature in many of those 
persons we have described as "moral defectives" or habitual 
criminals, who repeatedly (and often openly) commit offences 
absolutely undeterred by punishment. As an extreme instance 
of this the case related by Dr. Gray, lately physician to the 
Ameer of Afghanistan (mentioned in Dr. Mercier's book), is 
worthy of note. It is that of a man " who, after having had 
first his right hand, and subsequently his left hand, struck off 
as a punishment for theft, seized with his stumps and made off 
with an earthenware pot of trifling value, and of no use whatever 
to him. The crime was witnessed and the criminal at once 
arrested and taken before the Ameer, who sentenced him, as 
he must have expected, to be hanged ; and hanged he accord- 
ingly was." Dr. Mercier also mentions the case of a cadet at 
Sandhurst, who stole the boots and clothes of a comrade, although* 
he was amply supplied by his father, and had no need of the 
things stolen. He stole them without any concealment, and 
actually wore them in the presence of their owner. He was 
expelled, and on his return home, although standing in awe and 
terror of his father, nevertheless cleared the latter's dressing- 

* Charles Mercier, " Criminal Responsibility, " 1905. 

20 — 2 



308 Mental Deficiency 

table of its ivory brushes and silver furniture, and sold them to 
a passer-by for five shillings. 

Quite recently I was consulted with regard to an almost 
precisely similar case in the shape of a youth at a public school 
who, although liberally supplied from home, and having every- 
thing he needed, systematically purloined his companions' 
property of every description. This youth was by no means un- 
intelligent, in fact, in several subjects he occupied a high place 
in his form, and his general appearance and conversation were 
so prepossessing that anyone not acquainted with the type would 
almost certainly feel that some horrible mistake had been made. 
His only observable peculiarities consisted of a somewhat wander- 
ing attention, a general restlessness, and several little tricks 
such as constantly putting his hand to his collar, etc. And yet, 
when I questioned him about his misdeeds, he acknowledged 
them without any shame or concealment, and I found that he 
had been expelled from two other schools for similar practices. 
I am inclined to think that in some of the milder cases of this 
kind recovery may take place under suitable treatment and 
some degree of moral sense be developed ; but pronounced cases 
like these described are practically hopeless, and although it 
may be extremely difficult in some of them to detect any intel- 
lectual deficiency, and to differentiate badness from madness, 
the fact of such senseless depredations in spite of punishment 
would of itself lead one to infer that an intellectual defect did, 
in reality, exist. On the other hand, there can be no doubt that 
" moral deficiency," or as it is sometimes more euphemistically 
described " kleptomania," is often put forward as a defence when 
the individual is fully accountable for his actions. Personally I 
should be very loth to admit defective will-power as an excuse 
for a criminal offence unless the accused were of one of the types 
which have been described, or there were evidence of the previous 
commission of impulsive acts. 

(3) The commission of criminal acts in consequence of delusions 
practically only occurs in the case of aments who are also insane. 
These will be described in the following chapter, but here it may 
be stated that, although the combination of insanity and mental 
deficiency would raise a strong presumption as to the irresponsi- 
bility of the individual so affected, he could only justly and 



Moral Deficiency and Criminal Aments 309 

logically be held unaccountable for the commission of a criminal 
act when it was clearly shown that his mental disease did, in 
fact, prevent him from knowing the nature and quality of the 
act at the time it was done, or from knowing that the act was 
wrong, or from controlling his own conduct. For as Mr. Justice 
Stephen said : " An act may be a crime although the mind of 
the person who does it is affected by disease, if such disease does 
not, in fact, produce upon his mind one or other of the effects 
above mentioned in reference to that act." 

It is thus seen that, although an inquiry into the criminal 
responsibility of a person must, of necessity, take into account 
the state of that person's mind, yet the question is not in reality 
a medical, but a legal one. It is the duty of the physician to 
place before the court full and impartial evidence regarding the 
presence or absence of such mental disease, disorder, or deficiency 
as would influence conduct ; but it is the duty of the judge and 
jury to decide whether this defect or disease has so influenced 
conduct as to render the accused partially or wholly irresponsible 
for his act. 

In defining the " conditions of responsibility," Dr. Mercier 
arrives at the conclusion that " to incur responsibility by a harm- 
ful act, the actor must will the act ; intend the harm ; desire 
primarily his own gratification. Furthermore the act must be 
unprovoked, and the actor must know and appreciate the circum- 
stances in which the act is done." 

With regard to civil incapacity, an idiot has no civil rights, 
but a person suffering from feeble-mindedness could only be 
adjudged incapable of managing his affairs by proceedings 
in Chancery. In such a case trustees of the estate might be 
appointed without depriving the person of his liberty ; in other 
words, he might be declared incapable of managing his affairs, 
but capable of managing himself. 

An idiot is inadmissible as a witness, but in the case of an 
imbecile or feeble-minded person it is for the Judge to examine 
and ascertain whether he is of competent understanding to give 
evidence, and is aware of the nature and obligation of an oath ; 
if satisfied that he is, the Judge will probably allow him to be 
sworn and examined. 



CHAPTER XVII 

INSANE AMENTS 

In the literal sense of the word " insanity," all aments may be 
looked upon, and are often described, as " congenitally insane." 
But nowadays there is a tendency to restrict the term to those 
cases in which there is a perversion of the ego, and it is in this 
sense that it is here used. Dr. Savage says a man must be 
considered as sane or insane in relation to himself, and although 
such a definition would render " congenital " insanity an im- 
possibility, the variations of mental function and capacity in 
the mentally deficient are so great that, from the standpoint 
of amentia, there is much to be said in favour of using the ego 
rather than the "normal" or "mean average" as a standard 
of reference. 

A large number of aments react to their environment in a 
perfectly consistent, uniform, and, as far as their mental capacity 
will admit, normal manner, and such may be considered sane, 
albeit defective. On the other hand, a certain number are 
characterized by lapses from their ordinary mental state of such 
intensity that, for the time being, they may rightly be termed 
insane ; it is with these latter that this chapter deals. 

The causes which actually determine insanity are many and 
varied, ranging from a slight alteration of the general bodily 
health and condition to a sudden strain or prolonged mental or 
nervous stress. As Mercier says, however, " a jerry-built villa 
is liable to be blown down by a storm of wind, but nothing short 
of an earthquake will destroy a well-constructed mansion." And 
in the great majority of cases of insanity there is a predisposing 
cause — namely, an instability of nervous tissue. This instability 
may be congenital or acquired, generally the former, and, in 

310 



Insane Aments 311 

view of the defective structure which is the essential basis of 
amentia, it is not surprising that in many of these persons there 
should be a decided nervous instability and consequent proneness 
to insanity ; this is found to be the case. 

It is probable that the actual number of aments who are thus 
predisposed to insanity is incapable of determination, just as it 
is impossible to calculate the proportion of potential lunatics in 
the non-defective population ; but an approximate estimate of 
the number of the feeble-minded grade of aments who are actually 
insane can be made, and a comparison of this with the number 
of the ordinary insane will give an idea of the relative predisposi- 
tion in the two classes. 

From information which has been very courteously placed at 
my disposal by some asylum physicians, as well as from my own 
observations in the asylums of the London County Council and 
elsewhere, I am of opinion that at least 5 percent, of the inmates 
of the county and borough asylums of this country are feeble- 
minded insane ; we may therefore estimate the number of 
feeble-minded certified lunatics as approximately 4,450, or about 
8 per cent, of the total feeble-minded of the country (54,114). 

The proportion of ordinary or non-defective insane to the 
total population is only about 0*3 per cent., from which it appears 
that the predisposition to insanity in the feeble-minded is twenty- 
six times that of the ordinary population. There are, of course, 
many of the non-defective insane who are not certified, but so 
there are of the mentally deficient insane, and I think that these 
figures express the relative predisposition to insanity which exists 
in the two classes with tolerable accuracy. On the whole I think 
we may say that close on 10 per cent, of the feeble-minded have 
a definite insane predisposition. With regard to this tendency 
in imbeciles and idiots, I am unable to give any figures, but my 
impression is that, although it is considerably less than in the 
merely feeble-minded, it is still much greater than in the ordinary 
population. 

There is no doubt that a considerable number of the non- 
defective insane manifest signs of a diminished power of will or 
inhibition from a very early age, and some writers would go so 
far as to include these with the aments proper.* It cannot be 

* See Bolton, " Amentia and Dementia," Journal of Mental Science, 1907. 



312 Mental Deficiency 

denied that there is much to be said for such a view, for these 
persons often present a physiognomy, and also stigmata of 
degeneracy, identical with those existing in the mentally defec- 
tive. I doubt, however, whether these should really be classed 
as aments, although they are undoubtedly on the borderland 
between this condition and insanity, between a brain which is 
the seat of an actual arrest of anatomical structure and one 
which is merely unstable and of defective physiological poten- 
tiality. They serve to show that, just as the three grades of 
amentia merge into one another, so in turn do the mildest 
members of the aments stand in an extremely close relationship 
to the insane — that idiocy is, indeed, the culmination of the 
neuropathic diathesis. In this place, however, I shall use the 
term "amentia " in the manner in which it has all along been 
used, and shall only refer to those persons who show definite 
intellectual deficiency. 

In a certain number of these aments who become insane there 
are determining factors, just as in the ordinary lunatics ; but, on 
the whole, these factors are much less in evidence, and as we 
proceed down the scale of mental deficiency they become still 
less and less frequent. In the imbeciles an attack of insanity 
may suddenly appear without any apparent determining cause 
whatever, and the sudden and violent storms of the idiot, which 
must be looked upon as of precisely the same nature as true 
insanity, are similarly unrelated to any obvious cause. The 
extreme mental instability present in these persons must be 
considered as of itself sufficient to determine the attack: the 
" jerry-built villa " topples over, not by reason of any storm of 
wind, but because of its own unstable equilibrium. 

This instability, as I have already remarked, is usually present 
and recognizable from childhood. As a boy or girl the patient 
has been subject to fits of irritability, moroseness, or bad temper, 
often accompanied by acts of violence, which have been a cause 
not only of sorrow, but of anxiety, to friends and relations ; and 
although these conditions can hardly be termed insanity, they are 
the shadows of the coming event, being evidence of that special 
predisposition which will almost inevitably, sooner or later, 
terminate in insanity. It is possible that, could the youth and 
adolescence of a feeble-minded person of this class be passed 



Plate XXVII. 




T2 <u 
*0. 




bjo 
.5 

it: o* 



To face page 312.] 



Insane Aments 313 

in a perfectly orderly and routine manner, away from the bustle 
of the outside world, the attack might be long deferred, or even 
prevented. In the majority of cases, however, the first attack 
makes its appearance between the periods of puberty and 
adolescence, and in some cases even much earlier than this. 

One of the most frequent exciting causes in the mild aments 
is alcohol, to the action of which the mentally defective, and, 
indeed, neuropaths generally, seem to be peculiarly susceptible 
and particularly intolerant. A severe fright may likewise pre- 
cipitate an attack of insanity in one of these persons. I remember 
a mentally defective child who, for some breach of school disci- 
pline, was shut up by the teacher in a small dark room, little 
better than a cupboard. When taken out he was silent, and 
apparently dazed. The teacher said he was sulky, but he con- 
tinued moody and depressed, and a few days afterwards passed 
into a state of profound melancholia which necessitated his 
removal to an asylum. Religious or other forms of excitement 
may also act as determining causes. One small boy of twelve 
years became acutely maniacal as a result of the popular excite- 
ment attending the relief of Maf eking. Another mentally de- 
fective youth in the employ of an Evangelical clergyman was so 
worried by this zealous but indiscriminate gentleman about his 
soul that he attempted suicide. Another feeble-minded young 
man became insane in consequence of the repeated theatre- 
going and sight-seeing provided by his relations with the idea of 
amusing him. In fact, almost any trifling occurrence, which 
would have no effect upon the mind of a healthy person, seems 
to be enough to upset the equilibrium of these mentally unstable 
defectives, and often the mere physiological changes consequent 
upon puberty or adolescence are sufficient. 

I have already remarked that insanity is commoner in the 
milder than in the more severe grades of amentia, and in the 
latter it also tends to be of a somewhat different type to that 
in the feeble-minded. The insanity of the feeble-minded 
and high-grade imbeciles does not, on the whole, differ from 
that occurring in ordinary persons, and to give some idea of the 
relative frequency of the different clinical types, I may state 
that, in 62 of these cases which I had under my observation 
for a considerable period, mania was present in 32, melancholia 



3 1 4 Mental Deficiency 

in 16, alternating mania and, melancholia in 6, stupor in I, delu- 
sional insanity in I, and juvenile general paralysis in 6. I doubt 
whether the relative incidence of juvenile general paralysis is 
really so great as would appear from these figures, in consequence 
of the fact that the helpless demented condition of these persons 
leads to the committal of an undue proportion of them to asylum 
care. 

It will be of interest to give some particulars regarding the 
patients suffering from these different forms of insanity. 

Mania. — Fourteen of the patients suffering from mania were 
males, and eighteen females. In about two-thirds of the cases 
definite delusions were present, chiefly relating to the identity 
of the patients or those about them. In twelve of the cases there 
were well-marked aural or visual hallucinations. All these 
attacks presented the usual characteristics of acute mania, the 
patients gesticulating, shouting, singing, and rushing about, for 
days together without cessation. Sometimes they were exceed- 
ingly violent, using abominable language, and smashing every- 
thing within reach, so that confinement to the padded room was 
necessary. One girl of fourteen years attacked her brothers 
and sister with a poker and table-knives ; whilst another, aged 
sixteen, stabbed her grandmother and attempted to set fire to 
the house. One of these patients, who was recovering, accounted 
for his actions by saying that he " got some thought on his 
mind, which he tried to get off and couldn't ; this caused the blood 
to rush to his head, and sent it rushing down his arms and legs." 
I am of opinion that a considerable proportion of feeble-minded 
criminals are of this type, and that their offences are often com- 
mitted whilst they are actually insane. 

Melancholia. — Of the sixteen cases of melancholia, seven 
were males, and nine females. Definite delusions or hallucina- 
tions were ascertained to be present in three-quarters of the 
cases. In eleven patients suicide was threatened or attempted, 
and in seven there was refusal of food. Both active and 
passive varieties of melancholia occurred, the former being a 
trifle more frequent. The active form was commonly preceded 
or accompanied by terrifying delusions or hallucinations. Thus, 
one young girl was frightened by seeing a fight in the street ; 
she became timid and anxious, and in a few days developed pro- 



Plate XXVIII. 





I 



To face page 314.] 



Insane Aments 315 

nounced delusions to the effect that people were trying to kill 
and burn her. She heard voices threatening her, thought that her 
food was poisoned, and refused to eat it, and, in fact, became 
apprehensive of harm from every imaginable quarter. She was 
in a restless state of tearful agitation, constantly wringing her 
hands, and muttering, " What are they going to do to me ?" 
Another boy had the curious delusion that he had fallen to pieces 
and lost some of his parts. The passive form of melancholia of 
these persons seems at times to be the outcome of a morbid 
consciousness that they are not quite as other people. They feel 
neglected, or, as they sometimes say, " of no use." The rebuke or 
sharp word of employer or parent is keenly felt, and they acquire 
a habit of brooding over their fancied wrongs. It is very common 
to hear feeble-minded persons in this frame of mind complain 
that they have " not had fair play." Pronounced delusions of 
persecution soon follow, and these pass into a state of apathetic 
melancholia. If they can be got to converse at all, their remarks 
will often be to the effect that they are " tired of life and want to 
die," and, indeed, attempts at suicide are by no means un- 
common. These attempts are often real and definite efforts 
to put an end to existence, and drowning seems to be the method 
which most appeals to them. Many of these patients become 
utterly careless of personal cleanliness, refuse to work, dress, or 
take food, and sometimes resist any attempt on the part of their 
attendants to see to these matters for them. 

Stupor. — This, apparently, is not very common in the feeble- 
minded, but I have seen one well-marked case which, beginning 
as passive melancholia, with visual hallucinations and refusal 
of food, gradually developed into a condition of complete stupor 
— indeed, almost catalepsy. The patient was a mentally defec- 
tive boy of fifteen years, and for weeks he sat in one place, staring 
vacantly in front of him, dribbling from his mouth, requiring to 
be fed with a spoon, and absolutely indifferent to the calls of 
nature. He was discharged cured from the asylum in nine 
months, but readmitted six months later with a precisely similar 
attack. This in turn slowly passed away after a few months, 
to be followed by a state of extreme fatuity, the youth being 
liable to sudden outbursts of laughter or crying without any 
observable cause (see Fig. 67). 



3 1 6 Mental Deficiency 

Alternating Insanity. — In six of the cases the insanity took 
the form of alternating attacks of mania and melancholia. In 
these patients, however, there were no intervening periods of 
complete cessation, as in the folie circulaire of French authors. 
The mania, which was violent and acute, lasted for a time, and 
was then replaced by a state of melancholia of the ordinary 
variety, or vice versa, and so the process continued. Perhaps 
they should rather be classed as recurrent insanity. Two of them 
have now definite indications of approaching dementia. 

Delusional Insanity. — I do not think that a pure delusional 
insanity is common in aments, but one case seems to be best 
placed in this category. It is that of a feeble-minded youth, 
aged twenty-three years, who since the age of nineteen has re- 
mained in the same condition. There is neither excitement nor 
depression ; and he is quite happy and good-natured, telling 
every one that he owns a lot of money in the bank, that he 
teaches music at sixpence a lesson, and that he performs on the 
Aquarium stage. Not infrequently feeble-minded children and 
adults will, under the influence of delusions or hallucinations, 
make unfounded charges against their companions or teachers, 
and sometimes they will do the same from pure wickedness. It 
is very necessary to bear this fact in mind in any investigation, 
for the statements are often so circumstantial as to excite a 
ready credence in the unguarded. 

Recurrences. — In, about one-third of these cases there was no 
recovery from the first attack ; the mania or melancholia became 
lessened in its intensity, but persisted as chronic insanity, to 
gradually terminate in dementia. In about two -thirds of the 
cases, however, the first attack gradually and completely sub- 
sided after a period varying from a few weeks to two or three 
months ; but the improvement was only temporary, and, as far 
as my experience goes, there is scarcely any class of patient 
in whom a recurrence is more likely to take place. This is 
seldom deferred for more than a year, and in the majority of 
the cases it comes on within a few months of the subsidence of 
the original attack. The second and subsequent attacks are 
usually of the same clinical type as the first, and they continue 
to occur at periods varying from three to twelve months for 
many years. In the intervals the patient is fairly quiet, and 



Insane Aments 317 

may do a certain amount of useful work, although his mental 
deficiency and instability prevent any regular employment. 
With the lapse of time, however, the insane attacks tend to recur 
more and more frequently, and the patient gradually passes 
into a state of chronic insanity, which is only terminated by the 
development of dementia. 

Dementia. — Many aments become demented in their later 
years, and secondary dementia is the natural termination of most 
of these cases of insanity, its advent depending chiefly upon the 
type and the frequency with which recurrences occur. On the 
other hand, primary dementia in young aments is of such rare 
occurrence that its presence, without antecedent insanity or 
epilepsy, is nearly always indicative of juvenile general paralysis. 
In the insanity accompanying epilepsy, or even in severe 
epilepsy without insanity in these patients, dementia is usually 
ushered in fairly early. In the sudden and violent storms of 
the emotional type, on the other hand, ItTls late, and I have 
known such patients show no sign of dementia after many years. 
The ordinary attacks of insanity seem to lie midway between 
these two extremes, and in most of my cases definite symptoms 
of dementia were observable within about eight years of the 
first attack. 

It is thus seen that in the life cycle of the ament we may have 
an epitome of all the main varieties of mental disease. Beginning 
with a defective brain, he may early show signs of mental insta- 
bility and imperfect function ; this passes on into various types 
of insanity, and finally culminates in complete degeneration of all 
the little faculty he once possessed — dementia. 

General Paralysis. — My figures are not sufficiently numerous 
to enable me to state definitely to what extent this occurs, but 
amongst rather more than 200 aments in the asylums of the 
London County Council I met with six instances (three males 
and three females). The disease may be of the adolescent or 
of the ordinary variety ; but although a few cases of the latter 
have been recorded, I have not myself seen an example of it 
in an ament. Accepting the view that syphilis is the most 
common cause, one would suppose that the state of the nervous 
system of these persons would render them particularly liable 
to its action should they become infected ; possibly, however, 



31 8 Mental Deficiency 

the explanation of the comparative infrequency of the ordinary 
variety of general paralysis in aments may be that they are not 
so much exposed to the chances of syphilitic infection. 

In my cases the symptoms first made their appearance 
between the ages of fourteen and nineteen years, all the patients 
being well-marked aments. In three of them delusions of 
persecution were present, accompanied at one time by attacks 
of mania, at another by profound depression with attempts at 
suicide. In the other three cases the mental disturbance con- 
sisted of violent emotional storms. These conditions persisted 
with occasional exacerbations and remissions for from one to 
two years, when signs of dementia appeared. Several of these 
cases have already been described in the account of syphilitic 
amentia. 

Epileptic Insanity. — Many feeble-minded and imbecile epi- 
leptics are exceedingly irritable and liable to outbreaks of furious 
passion, and a considerable number develop insanity just the 
same as do ordinary epileptics. There are no special features, 
and the tendency is usually to early dementia. 

Insanity in Imbeciles and Idiots. — Insanity occurs in the 
severer as well as in the milder grades of amentia, and it may 
take the form of excitement or depression. It follows, however, 
from the very imperfect mental development of these persons, 
that the disturbance is less often of an ideational than emo- 
tional character ; it is also usually of shorter duration than in 
the case of the mild aments. Most insane attacks in pronounced 
imbeciles and idiots take the form of sudden and violent 
maniacal attacks. During these the child or youth will rush 
about, making hideous noises, overturning or smashing every- 
thing in his way, animate as well as inanimate, and often dashing 
himself with great violence against walls, doors, and articles 
of furniture which he cannot displace. Such attacks are liable 
to recur at more or less frequent intervals. 

Illustrative Cases. 

Case i. Feeble-mindedness ; Attack of Acute Mania with 
Delusions lasting Six Weeks ; Recovery ; Discharge. — C. H. C, 
a feeble-minded youth with several well-marked stigmata of 
degeneracy; said to have always been very excitable ; no regular 



Insane Aments 319 

employment. Admitted to the asylum, aged sixteen, with 
acute mania of three weeks' duration. He had suddenly become 
noisy and sleepless, throwing himself into strange attitudes, 
utterly irrational in his conversation, shouting out " God save 
the Queen," and asking to be allowed to fight the Boers ; alter- 
nating with this he was tearful and anxious, with delusions of 
being constantly followed by policemen, and by boys who called 
" Thief !" after him. He was in a state of restless agitation, 
begging for the door to be kept locked. For a week after admis- 
sion to the asylum he remained in this excited condition day and 
night, and it was quite impossible to control him. He was terrified 
of the other patients, thinking they were all trying to strangle 
him. After a week he gradually became quieter, and at the 
end of two months had become so quiet and well-behaved that 
he was able to be discharged. 

Case 2. Feeble-mindedness ; Attack of Acute Mania with Delu- 
sions and Hallucinations, subsiding in Two Months ; Subsequent 
Recurrences for Two Years ; Signs of Dementia. — A. C, male, 
aged twenty-five years. Has always been backward, and never 
learnt to read or write. After leaving school earned a few 
shillings weekly by doing odd jobs, but had no regular employ- 
ment. Apt to behave queerly at times from early boyhood, 
and on several occasions disappeared from home for two or 
three days. At the age of twenty-four began to attend music- 
halls frequently, and shortly afterwards became exceedingly 
strange in his manner ; he refused to do any work, and spent 
most of his time standing at the open window talking to people 
he imagined he saw. Much of his conversation was about one 
"Flo Arnold/' whom he wished to marry, for which purpose 
he said he had taken £2 out of the bank. He gradually 
became quarrelsome, and finally violent and acutely maniacal, 
and had to be sent to the asylum. This condition of mania, 
with delusions and aural hallucinations, lasted for two months, 
after which he became quieter. He has now been in the asylum 
for nearly two years. He is subject from time to time to sudden 
outbursts of maniacal excitement, lasting from a few hours to 
several days ; these are probably due to delusions, although 
none can be ascertained. He shows indications of the onset 
of dementia. 



320 Mental Deficiency 

Case 3. Feeble-mindedness ; Attack of Acute Mania, aged 
Sixteen, passing into a Condition of Recurrent Insanity ; no 
Dementia after Three Years. — A. F., female. "Always simple 
from quite a child." Left school aged twelve, being only in 
second standard ; afterwards in a training home ; very bad- 
tempered and addicted to smashing windows ; sent home after 
three years, as they found they could do nothing with her. At 
the age of sixteen she became so violent that she had to be 
removed to the asylum, having previously hurled a cooper's 
hammer at a man and thrown a heavy padlock at a woman. 
She remained in a condition of maniacal excitement for three 
months, with an occasional short interval of comparative calm. 
During one of these I asked her why she behaved so violently ; 
she said something came over her and she felt she " must do it." 
In the next three months she became much quieter, and for the 
following five months she remained silent and gloomy, refusing to 
have anything to do with the other patients ; then she relapsed 
into a state of restless excitement lasting for a month, followed 
by another period of depression. She is now nineteen years of 
age, having been in the asylum three years. She is at times 
fairly quiet and does a little ward work, but is very untrust- 
worthy, and liable to sudden outbursts of maniacal excitement 
with destructiveness ; she is highly emotional and unstable, 
bursting into fits of tears or laughter without any apparent 
cause. There are no indications of dementia. 

Case 4. Feeble-mindedness ; Attack of Acute Mania, aged 
Sixteen ; Constant Recurrences, at Times accompanied by Delu- 
sions ; under Observation Four Years ; no Improvement. — R. D., 
female. Very backward at school ; left aged thirteen and 
went to service, but was so liable to what her mother calls 
"fits of temper" that she could not keep any situation more 
than a few months ; altogether she had fourteen situations 
in less than three years. At the age of sixteen she be- 
came so violent that she was sent to the asylum. On admis- 
sion she was in a state of acute mania, screaming, shouting, 
singing, and resisting all attempts to keep her in bed ; she also 
threatened to cut her throat. This condition lasted for a few 
days after admission ; she then became quieter, and by the end 
of a fortnight was doing some work in the wards. Within a 
month she had a relapse exactly similar to the first attack. She 



Insane Aments 321 

is now twenty years of age, and has been in the asylum four 
years. At times she is quiet, well-behaved, and answers ques- 
tions readily and pleasantly ; it is, however, quite impossible to 
depend upon her, and she is subject from time to time to sudden 
outbreaks of excitement, in which she becomes most abusive, 
uses the foulest language, and violently attacks anyone who 
may be in her way. These outbursts last for three or four days 
and nights ; as a rule, they seem to be purely emotional storms, 
but in some of them delusions are present, generally to the effect 
that the medical officers and the nurses are trying to cut off her 
head or to torture her in various ways. 

Case 5. High-grade Imbecile ; Attack of Acute Mania subsiding 
in Three Months, followed by Frequent Recurrences ; under 
Observation for Seven Years without any Improvement. — E. S., 
female. Simple-minded from birth ; did not get on at school ; 
subsequently kept at home to help mother, " as she did not 
seem to have enough sense to go out to work " ; was at times 
very troublesome, and caused much annoyance by suddenly 
rushing into the neighbours' houses. At the age of sixteen 
became so restless and excitable that they could do nothing with 
her, and sent her to the asylum. The medical certificate states 
" she exhibits undue mental excitement, talks, sings, shouts, 
and laughs immoderately, and behaves in an insane manner ; 
very restless, imagines the attendants to be her former school- 
teachers, and seems altogether too excited to control herself 
and talk sensibly." This acute condition gradually abated, and 
by the end of three months she had become quiet and able to 
do work ; two months later she relapsed, again becoming excited 
noisy, and destructive day and night, in which state she remained 
for three weeks, then becoming quiet and industrious again. 
She has now been in the asylum seven years, has ceased to do 
any work, and is subject to frequent acute outbreaks of noisy 
aggressiveness. In some of these attacks delusions are present ; 
thus, a short time ago she stated that she had given birth to 
a child, which had been stolen from her in the night. She 
is very impulsive, and on one occasion, seeing a pail of water 
standing in the ward, she suddenly plunged her head into 
it. She is becoming very untidy in her dress and personal 
appearance, though there are as yet no other indications of 
dementia. 

21 



322 Mental Deficiency 

Case 6. Medium-grade Imbecile ; Attack of Acute Mania, 
aged Fourteen ; Condition practically unchanged at the End of 
Six Months. — C. R., female. Never passed first standard at 
school ; subsequently kept at home ; could never be depended 
upon ; and from nine years of age has been at times very 
violent and addicted to using disgusting language. She had 
to be sent to the asylum at the age of fourteen, and on admis- 
sion was in a state of mania, chattering to herself and singing 
or shouting the whole day. At times destructive and aggres- 
sive ; very restless at night. She has now been in the asylum 
for six months, and on the whole there is very little improvement. 
She is occasionally fairly quiet and rational, but as a rule she is 
raging up and down the wards singing, shouting, and swearing 
at the other patients. The charge-nurse says she is her most 
troublesome patient. 

Case 7. Feeble-mindedness ; Attack of Melancholia with Hal- 
lucinations and Delusions, passing into a Condition of Recurrent 
Insanity ; Signs of Dementia in Six Years. — C. D., male. He 
could never learn arithmetic at school, as the master said his 
" brain was too weak." Used to behave very oddly at times. 
After leaving school was employed in a bootshop. At the age 
of sixteen he was frightened by a large black dog, and shortly 
afterwards became much depressed, gradually passing into a 
condition of melancholia. On admission to asylum he was found 
to have aural and visual hallucinations with delusions. He 
thought he was surrounded and threatened by black men ; he 
said that he was afraid he was going to be killed in the China 
War, and that God told him to kill himself. For several days 
he was restless and anxious, afterwards becoming dull, listless, 
lethargic, and a confirmed masturbator ; he would occasionally 
waken out of this stuporose condition to become aggressive and 
violent. Four years after admission he had so much improved 
that he was discharged to his friends, only to be readmitted six 
weeks later, as they found it impossible to manage him. He is 
now twenty-two years of age, and is still in the asylum, being 
idle, and as a rule dull and depressed and constantly muttering 
to himself ; occasionally destructive and aggressive ; signs of 
dementia are apparent. 

Case 8. Medium-grade Imbecile; Attack of Melancholia with 
Attempted Suicide ; Recovery in Four Months ; Relapse Eigh 



Insane Aments 323 

Months afterwards ; now again recovering. — T. K., male. Mental 
deficiency noticed from early childhood ; incapable of learning 
at school ; no work subsequently ; never earned any money. 
Gave much trouble to his parents, being " very bad-tempered," 
and frequently wandering away from home. At sixteen years 
of age became much depressed, and attempted suicide by taking 
carbolic acid. On admission into asylum was wretched and 
tearful, saying that he wanted to die, and there was no reason 
why he should Hve. He gradually became brighter and even 
cheerful, and a month after admission was able to work out of 
doors ; the improvement continued, and he was discharged in 
four months. Eight months later he was readmitted, having 
been found by a policeman battering his head against some iron 
railings. On the way to the station he said that he would kill 
either himself or his father, the latter stating that he had been 
violent and had attempted to cut his (the father's) throat. He 
was profoundly depressed, thought he heard voices, and that 
people had conspired to kill him. At the present time he has 
been in the asylum four months. He is still depressed and 
solitary, but on the whole decidedly brighter, doing a little work, 
and appears to have lost his delusions. 

The following case of General Paralysis in an Adult Ament is 
recorded by Dr. Cappelletti :* 

The patient, a female imbecile aged fifty-four years, was turned 
out of her home by her brother, and came to great want ; she was 
taken into the asylum in a maniacal condition. She had a small j 
asymmetrical skull, tremor of tongue, face, and extremities, 
hesitating and tremulous speech, wide, unequal pupils which only 
reacted feebly to light and accommodation. No signs of syphilis 
on the body. Mental condition exalted, with grandiose ideas. 
Death occurred after two years in consequence of apoplectiform 
attacks. Post-mortem examination showed thickening of the 
dura and pia, with adhesions and cortical erosions. Small 
frontal lobes, asymmetrical hemispheres, and a narrow grey 
substance. The basal arteries were atheromatous. 

The author refers to two other similar cases which have been 
described, and in a subsequent note states that the asylum 
register at Ferrara shows the existence of a fourth. 

* Neurolog. Centralbl., 1898, p. 558. 

21 — 2 



CHAPTER XVIII 

DIAGNOSIS AND PROGNOSIS 

The physician who is consulted with regard to a possibly mentally 
deficient person will be expected to answer three questions. 
First, Is amentia really present ? Secondly, To what extent 
can it be improved ? Thirdly, What is the form of treatment 
to be adopted ? These three matters of diagnosis, prognosis, 
and treatment will be dealt with in the present and succeeding 
chapters. 

Diagnosis. 

The question of diagnosis has already been considered to a 
great extent in previous chapters, particularly that referring to 
mentally defective children ; it will, however, be convenient to 
summarize the chief points to which attention must be paid. 

In infants the symptom which usually first attracts atten- 
tion, and which causes the parents to seek advice, is the presence 
of abnormal nerve signs. Briefly, there is either a state of 
torpid, listless indifference, so that the child makes no attempt 
to suck, does not look about him, does not cry, and, in fact, is 
generally lacking in spontaneity ; or the reverse of this con- 
dition is present, the child being abnormally restless, always 
crying and tossing about, and getting hardly any sleep. In 
cases of severe amentia, one or other of these states is generally 
present during the first twelve months. The latter, however, 
attracts most attention, for mothers are inclined to look upon 
the former as merely an excessive amount of " goodness," and, 
at first, to congratulate themselves accordingly. 

But these conditions, although abnormal and indicative of 
brain disturbance of some kind, are not diagnostic of amentia. 

324 



Diagnosis and Prognosis 325 

They may result from inadequate or improper feeding, causing 
general malnutrition, or from some more serious bodily disease. 
The first care of the physician, therefore, must be to make a 
thorough physical examination of the child, and particularly 
to exclude such morbid states as anaemia, rickets, malnutrition, 
bone caries, the various forms of tuberculosis, otitis, meningitis' 
cerebral abscess, and reflex causes of nervous irritation. 

Having done this and ascertained that there is no bodily 
condition responsible for the nervous abnormality, he has still 
to decide whether he is dealing with a child prefer naturally dull 
and stolid, with one unduly excitable and neurotic, or with one 
who is really mentally deficient. Here the family history and 
the presence of stigmata of degeneracy or features peculiar to 
certain varieties of amentia will be of great value. 

If with either of these abnormal nervous states there is asso- 
ciated a pronounced morbid heredity, there is a strong prob- 
ability that the child will turn out to be mentally deficient. 
If stigmata of degeneracy are present in addition, this prob- 
ability is greatly increased, and a diagnosis may thus be possible 
in the early months of life. If special features exist, such as 
the abnormally small skull of the microcephalic, the peculiar 
physiognomy of the Mongol or cretin, the changes in the fundus 
of infantile cerebral degeneration, or even marked paralysis, the 
diagnosis may be made with certainty. 

But even if stigmata be absent, and the child's condition be 
plainly due to brain disease without neuropathic predisposition, it 
must still be remembered that serious disease of the brain occur- 
ring in early life may terminate in secondary amentia, if death 
does not previously end the scene ; whilst this possibility is 
greatly increased in the presence of morbid heredity. The 
association of continuous epileptic convulsions with any of 
these conditions greatly adds to the unfavourable outlook as 
to the future mental development. 

In cases seen somewhat later — say during the years of child- 
hood — there is less difficulty in arriving at a diagnosis. Not 
only is there the great advantage of a longer life history, and 
consequently more information forthcoming as to general 
behaviour ; but, since by the age of five or six years the normal 
child has made considerable intellectual advance, the arrears 



326 Mental Deficiency 

of the mentally deficient one at this age are by contrast much 
more apparent. Idiocy, imbecility, and pronounced feeble- 
mindedness can now hardly fail to be detected, and the chief 
difficulty experienced will be with regard to the mildest degrees 
of intellectual or moral defect. It is still necessary to remember 
that amentia may be simulated by bodily ill-health or disease, 
is well as by delayed development or dullness of intellect not 
amounting to defect. These conditions have already been 
fully referred to in treating of mentally deficient children. 

At a still later age, or in the adult, it is again practically only 
the milder cases which give rise to any real difficulty of diagnosis. 
Amongst the wealthy classes, or where property is concerned, 
such cases may form the subject of a judicial inquiry, and the 
greatest care must be taken in arriving at and stating an opinion. 
This will be based upon a careful examination of the patient's 
mental capacity, as revealed by his manner, conversation, and, 
if necessary, the way in which he discharges some test com- 
missions entrusted to him, as well as by a consideration of his 
previous general behaviour ; also by attention to the presence 
of stigmata of degeneracy and a neuropathic family history, 
as indicative of primary amentia, or the well-marked history 
and signs of brain disease which usually accompany secondary 
amentia. 

The question which has to be answered is, Is this person 
capable of competing on equal terms with his normal fellows, 
or of managing himself and his affairs with ordinary prudence ? If 
he be not thus capable, then he is probably suffering from mental 
deficiency ; but such a condition may also be due to insanity or 
early dementia, and these will require to be excluded. In most 
cases attention to the previous history and to the nature and 
motive (or absence of motive) of the acts committed or omitted, 
as the case may be, will settle the point. It is, however, to be 
remembered that, whilst delusions are common in both insanity 
and dementia, they may also occur in aments. In fact, insanity 
with delusions is a not infrequent complication of mild mental 
deficiency. 

A person who recklessly distributes his possessions or im- 
poverishes himself by expending large sums of money on objects 
for which he has not the slightest use, under the delusion that 



Diagnosis and Prognosis 327 

he is acting as the almoner of the Almighty or is the richest man 
on earth, is probably insane or demented. But if he does these 
things in consequence of an inability to realize the value of 
money, and his purchases are such as would only bring delight to 
a child ; if he shows a complete incapacity for business manage- 
ment, an undue credulity, and a lack of sense of responsibility ; 
if, further, he is content to be left with the barest necessities 
of life, whilst his patrimony is plundered by his acquaintances 
under his very eyes, he may justly be regarded as mentally 
deficient. 

Perhaps the greatest difficulty of all in deciding whether 
amentia is present or not is experienced in certain cases present- 
ing moral defect or perversion, and which come before the criminal 
courts. High-grade aments, non-defective but mentally un- 
stable persons, and thriftless, irresponsible ne'er-do-weels and 
wastrels, form a very large proportion of that section of man- 
kind which is on the down-grade. A large number of them are 
liable to commit offences against law and society ; indeed, it 
is from these classes that the great majority of our criminals and 
paupers are drawn. It is here that a decision as to whether 
mental deficiency is or is not present may be extremely difficult. 
It is impossible to lay down any rules, for each case must be 
considered on its merits ; but I think that attention to the family 
history, the life history and previous behaviour of the patient, 
together with a careful examination of his bodily and mental 
condition, will usually enable a decision to be made. 

Prognosis. 

Having ascertained that amentia is really present, the 
physician will next be called upon to say to what extent it may 
be remedied by treatment. 

Until sixty years ago cases of pronounced mental deficiency 
were considered to be absolutely and hopelessly beyond any 
possibility of amelioration. But in 1846 Dr. Edouard Seguin* 
demonstrated to the world the capacity possessed by many of 
these persons for considerable improvement under patient and 
systematic training, and since then the pendulum has gradually 

* Edouard Seguin, " Idiocy, and its Treatment by the Physiological 
Method," New York, 1866. 



328 Mental Deficiency 

swung to the other extreme. At the present day the training 
of the mentally deficient occupies a more or less important place 
in the social system of most civilized countries, and it is even 
questionable if there be not a tendency to overestimate the 
educational possibilities, and to think the machine only needs 
to be sufficiently elaborate in order that the entering idiot may 
emerge a person of normal intelligence. 

Both these views are wrong, and are to be deprecated. On 
the one hand, there are comparatively few cases so bad that 
they cannot be improved to some extent, if only in habits 
of cleanliness and the curtailing of destructive and dangerous 
propensities. On the other hand, no case of real amentia (with 
the exception of cretinism) ever becomes cured. However mild 
it may be, some defect will always remain, and this will render 
competition on an equal footing with the normal population 
impossible. 

And here it is necessary to enter a protest against the practice 
adopted by some medical men, of telling the parents that the 
child will " grow out of it," or that he will be " all right when 
he is seven," or " fourteen," or " twenty-one." In some cases 
this is done from ignorance of what amentia really is, in others 
from a benevolent but mistaken idea of sparing the parents' 
feelings. Where the physical condition of the patient is such 
that death cannot be long delayed, the disquieting knowledge 
that idiocy is present may perhaps be withheld ; but in other 
cases the interests of the patient demand that the parents 
should be told the truth, for much of the early training so neces- 
sary for improvement will be in their hands. I have known 
children dragged about from doctor to doctor and from quack 
to quack in the vain hope of seeing that change which had been 
confidently foretold, but which never came. I have known 
many pounds spent on nostrums, electrical and galvanic appli- 
ance xidst the child was rapidly deteriorating for want of 
systematic training ; but I have rarely met parents who were 
other than grateful, though sad, when the real truth was kindly 
told them. Few people like living in a fool's paradise, and in 
this case it is not a paradise, for there is often the lurking 
suspicion that something is really wrong, and that the practi- 
tioner does not understand the case. 



Plate XXIX. 





E"S 

-* P 



To face page 316.] 



33° Mental Deficiency 

more pronounced cases, even, can be taught to do some useful 
work in the garden or on the farm. 

In cases of secondary amentia due to toxic or vascular disease 
of the brain, the prognosis, as already remarked, is on the whole 
decidedly less favourable than in primary aments ; but it differs 
very greatly according to the nature of the lesion. In cases in 
which, after the infliction of the damage, the pathological lesion 
ceases to progress, and serious secondary anatomical changes are 
not induced, the prognosis is tolerably good, always provided 
that appropriate training is begun sufficiently early. Many cases 
of birth injury and purely vascular lesions occurring in very early 
life are of this nature, and the improvement is probably brought 
about by neuronic compensation. Many of these persons who 
suffer from severe paralysis even may be educated to read, write, 
sum, and do mechanical work with surprising dexterity ; but there 
is usually a little childishness, a want of judgment regarding the 
affairs of life, and an inability to make headway against com- 
petition. Dr. Shuttleworth* mentions such a case presenting 
right hemiplegia with athetosis attributed to injury at birth, 
who was admitted into the Royal Albert Asylum at the age of 
twelve years. " In spite of his physical drawbacks, he rapidly 
developed graphic abilities, and after a course of scholastic 
instruction in writing, drawing, reading, etc., with suitable 
physical and manual exercises, he was trained to woodwork in 
the joiner's shop, where he gradually attained such control over 
his irregular movements that he became an expert workman, 
making tables, chests of drawers, and decorative sideboards. 
He showed a nice taste for wood-carving, and ultimately became 
so skilful in it that he is now employed as instructor in this art. 
He is also a clever scene-painter. He is now practically ambi- 
dextrous, his right hand having been trained to be serviceable." 

It is, of course, to be remembered that in many of these cases 
of birth paralysis the lesion concerns the motor centres of the 
brain only, the child subsequently appearing, but not in reality 
being, mentally deficient because his crippled condition has pre- 
vented his attendance at school. 

On the other hand, in cases where the lesion is active or induces 
progressive pathological changes, the prognosis is decidedly 

* G. E. Shuttleworth, "Mental Deficiency in Children," British Journal 
of Children's Diseases, March, 1904. 



Diagnosis and Prognosis 331 

unfavourable, and in a considerable number dementia sooner or 
later supervenes. The majority of these are characterized by 
epileptiform or epileptic convulsions. 

Amentia due to epilepsy is decidedly unfavourable, being, in 
fact, one of the most hopeless varieties. For epilepsy which 
has produced amentia will probably end by producing dementia. 
In other cases of mental deficiency, in which epilepsy is a com- 
plication and not the cause, it is still a highly unfavourable symp- 
tom, and imposes a considerable barrier to successful education. 

In sclerotic amentia the most hopeful cases are those in which 
enlargement of the skull takes place. The majority of cases of 
pronounced sclerosis with crania of normal or diminished size 
die before, or soon after, attaining the age of puberty. 

In hydrocephalus everything depends upon the course of the 
disease, which can never be foreseen. Rapidly progressing expan- 
sion of the skull is almost invariably fatal ; but in cases where spon- 
taneous arrest takes place, the resulting mental impairment may 
be but slight, and may be largely remedied by suitable training. 

In syphilitic amentia, in view of the tendency to the develop- 
ment of general paralysis, the outlook is decidedly bad ; whilst 
in infantile cerebral degeneration it is hopeless. 

In cretinism the prognosis is, on the whole, dependent upon 
the age at which treatment is begun and the persistence with 
which it is carried out. As already mentioned, however, it is 
possible that other factors may influence the result — e.g., the 
presence or absence of morbid heredity. 

Amentia due to isolation or sense deprivation is curable provided 
special education is begun sufficiently early, and even in cases 
which have been neglected for years it is remarkable what results 
may follow patient and systematic training. 

Prognosis regarding the Degree. — Finally, a few words may be 
said with regard to the degree of amentia. In the absence of 
contra-indication, such as epilepsy or the special pathological 
processes just mentioned, the amount of improvement and the 
final result will, of course, be dependent upon the degree of initial 
defect. This cannot always be gauged, but some measure of it 
will be afforded by a careful comparison of the physiological and 
psychological development of the patient with that of a normal 
child of corresponding age. Regarding this, reference may be 
made to the Table of Normal Developmental Data on p. 364. 



CHAPTER XIX 
TREATMENT AND TRAINING 

I.— MEDICAL AND SURGICAL TREATMENT. 

There is no drug which has the slightest direct or specific in- 
fluence upon primary mental deficiency, and, we may safely 
assert, there never will be. Considering that this condition is 
the outcome of a neuropathic diathesis, due in many cases to 
generations of antecedent disease, we can no more hope to relieve 
it by medicaments than we can hope by such means to transform 
the worn-out tissues of age into the virile ones of youth, or to 
restore life to the dead. 

With regard to secondary amentia, there is one form, cretinism, 
for which a specific exists. It may even subsequently be dis- 
covered that there are other varieties of secondary amentia 
due to definite qualitative anomalies of blood-supply, and for 
these the corresponding specific may also be found. Possibly, 
as already mentioned, some cases of Mongolism may be of this 
nature. But if such cases do exist, it may safely be stated that 
they are exceedingly rare, and in the great majority of in- 
stances of secondary amentia, as well as of primary, drugs have 
no direct influence. Pituitary and thymus, as well as other 
glandular extracts, have been tried without the slightest avail ; 
and even the amentia which is directly due to syphilis shows 
not the slightest improvement under antisyphilitic treatment. 

The same must be said of surgical treatment. When the 
theory was propounded that microcephalus was due to prema- 
ture synostosis, it was natural that the surgeon should suggest 
relief by craniectomy. During the year 1890, and for a time 
after, a considerable number of operations were performed by 

332 



Treatment and Training 333 

eminent men, chief of whom may be mentioned Lannelongue 
(Paris), Victor Horsley (London), and Keen (Philadelphia). The 
cases operated upon were not only microcephalics, but included 
other varieties of amentia. The mortality was exceedingly high 
(about 25 per cent.), and those who survived showed no mental 
improvement. It is not surprising that the operation should 
have gradually been abandoned by reputable surgeons, and to-day 
it is practically unheard of. It was, indeed, founded upon a 
mistaken notion as to the pathology of this condition, and it 
may be said that to-day operations of this kind upon cases of 
primary amentia are absolutely unjustifiable. 

The case is somewhat different with regard to certain varieties 
of secondary amentia. Where there is no morbid heredity, and 
where there is clear evidence, or even a reasonable presumption, 
that the deficiency is due to fracture, splintering of the inner 
table, or other conditions causing increased cranial pressure, 
then not only is operation justifiable, but it is the duty of the 
physician to advise it at the earliest possible moment, and before 
changes have been induced which may be irreparable. I must 
confess, however, that I know of no statistics sufficiently exten- 
sive to show the results of operation in such cases. 

Nevertheless, it is not to be assumed that medicine or surgery 
have no place in the treatment of amentia. This is far from 
being the case, for mens sana in corpore sano is a true saying, 
and medicine and surgery can do much to promote the bodily 
well-being of these persons. I am no advocate for the systematic 
drenching of the ament with drugs, or for the performance upon 
him of operations which can contribute nothing to the improve- 
ment of his body or mind ; but it cannot be doubted that con- 
ditions are often present which stand in the way of efficient 
training and which are amenable to treatment ; and it is certain 
that education will be attended with most success when every 
means have been employed to place the body in the best 
possible condition. 

Before systematic education is begun, therefore, it is of great 
importance to ascertain the existence of disease, disorder, or de- 
formity, and to correct the same by appropriate remedies, if such 
be possible. It is unnecessary to describe all the diseases and ail- 
ments which may affect the mentally deficient child ; their name 



334 Mental Deficiency 

is legion, and the chief of them have already been referred to in 
previous chapters. It may be stated, however, that conditions 
which particularly call for treatment are adenoids, enlarged ton- 
sils, nasal polypi, cleft palate, carious teeth, errors of refraction, 
disease of the ear, phimosis, hernia, webbing of the fingers, etc. 
Troublesome contractures may often be relieved by tenotomy, 
and where club-foot is present, walking may be greatly improved 
by suitable surgical boots. Medical treatment is called for in 
anaemia, malnutrition, and many disorders of the circulatory, 
respiratory, alimentary, and cutaneous systems. Troublesome 
constipation is best met by attention to the diet and the adminis- 
tration of cascara sagrada. Diarrhoea is often caused by im- 
perfect mastication or unsuitable food, and may need antiseptic 
or astringent treatment. Extract of malt, with or without cod- 
liver-oil, is valuable in severe malnutrition. Epilepsy is best 
treated by a careful control of the diet and daily life ; but if this 
fails, the frequency and severity of the attacks are often checked 
by borax and the bromides. A single dose of the latter at bed- 
time is often useful in allaying the undue instability so common 
in many of the milder defectives. Enuresis, a frequent com- 
plication, is best treated by accustoming the child to evacuation 
at regular periods. It may be helped by withholding all fluid 
for at least two hours before retiring, and in many cases a few 
nightly doses of one of the bromides will serve to check the habit. 
In addition to these indications for special treatment, the 
food, clothing, exercise, cleanliness, and general hygiene of these 
persons demand the closest attention. The dietary must be 
on a liberal scale, but plain, and excess of meat must carefully 
be avoided. Where mastication is imperfect, recourse to spoon 
food is often necessary, and this is always the case with the low- 
grade idiots. The danger of asphyxia from the impaction of 
food in the glottis is no fancy, and many cases of aspiration 
pneumonia have been recorded. Attention to the clothing is 
particularly called for in the Mongolian variety, as well as 
in other patients prone to catarrhal and circulatory disturbances. 
In the cold weather, the wearing of gloves may prevent trouble- 
some chilblains. Daily exercising and bathing must always be 
enforced, and the greatest care must be taken that rooms are 
sunny, not too warm, and thoroughly well ventilated. The 



Treatment and Training 335 

marked predisposition which many of these persons evince to 
the development of tuberculosis must be kept well in mind. 

It is unnecessary to enter any further into the details of 
medical, surgical, and hygienic treatment, since the principles 
are the same in these as in ordinary children. The only point 
I wish to insist upon is that mental deficiency is often — in- 
deed, usually — accompanied by bodily deficiency, disorder, and 
disease, and that the treatment of these latter is an essential 
prelude to. or accompaniment of, the training of the mind. 



II.— EDUCATION. 
General Principles. 

Having done our best, by careful attention to the laws of 
hygiene — aided, where necessary, by medicine and surgery — 
to remove any likely impediments to training, and to bring 
the mentally deficient child into the best possible physical 
condition, the question of education must be considered. In 
the following pages I shall deal with the general principles upon 
which such should be based, particularly those which concern 
the physician. The actual pedagogic methods to be employed 
are beyond the scope of this work, and, for the most part, can 
onl} 7 be acquired by practical experience. 
H^ Education has a threefold object. First, it should develop 
and cultivate all the latent potentialities of body and mind to 
their fullest extent ; secondly, it should repress or eliminate vices 
and faulty modes of action ; thirdly, it should supply, if possible, 
such particular instruction as will fit the individual for some 
useful form of work. In other words, it should aim at im- 
parting knowledge as well as inculcating wisdom. The two 
former of these objects are educational in the literal sense of the 
word ; the latter may be looked upon as technical instruction. 

The development of mind takes place in consequence of two 
influences : spontaneity , or an inherent tendency of the brain 
cells to develop ; and stimulation of these cells by external im- 
pressions. The brain of the healthy child has an inherent 
potentiality which makes it to a certain extent independent, of 
its environment ; or perhaps I should rather say that it is capable 



336 Mental Deficiency 

of utilizing and responding to any surroundings, within ordinary 
limits, in which it may be placed. A little friend of mine, aged 
four years, reads " Alice in Wonderland " with remarkable 
facility. She has never had a single formal lesson, and her 
knowledge was picked up solely by observing letters and asking 
questions. The defective mind is lacking in this power. One 
of its chief characteristics, if not the chief, is a want of what 
may be termed mental aggressiveness ; consequently its develop- 
ment has to be aided and encouraged by special means. At 
the same time, the deficient power of control often gives full 
play to the lower organic feelings, resulting in vices, antisocial 
acts, and crimes. These tendencies have to be eliminated. 

Until sixty years ago the training of the mentally deficient, 
where such was attempted, was conducted upon no logical 
method, and it is to Dr. Edouard Seguin that we owe the first 
clear enunciation of the principles upon which it should be 
based. In his words, education " consists in the adaptation 
of the principles of physiology, through physiological means 
and instruments, to the development of the dynamic, perceptive, 
reflective, and spontaneous functions of youth." By the pains- 
taking and laborious application of these principles, Seguin 
himself demonstrated the remarkable results which may take 
place even in apparently hopeless idiots ; and upon his principles, 
extended and elaborated by the work of Froebel and Pestalozzi, 
most of our present methods are based. 

The method of applying these principles, in brief, is to take 
each "function" or "faculty," each physiological system of 
neurones, and, by means of appropriate and carefully arranged 
progressive exercises, to develop them to the fullest extent of 
their capacity. I do not, of course, mean to suggest that we 
can isolate and develop separately each " function." All 
portions of the mental apparatus are interdependent, and 
education is a general process which simultaneously concerns 
the development of the bodily as well as the sensory, motor, 
intellectual, emotional, and moral functions. But it is con- 
venient for purposes of description to make this division, and it 
tends to emphasize the fact, that as the child's development 
naturally takes place in a regular progressive order, so must the 
training be progressively adapted to its growing needs. 



Treatment and Training 337 

In many cases it is first of all necessary to arouse spontaneity. 
The child is inert, and must even be stimulated to play ; until 
this is accomplished, and some interest is aroused, any further 
training is, of course, impossible. Having succeeded in arousing 
some degree of initiative by means of romping play, this is 
gradually replaced by more definite games, and then by orderly 
drill and calisthenics. In this way spontaneity becomes con- 
trolled in accordance with a definite purpose, and the child 
learns to acquire the habits of obedience and attention. This 
naturally leads up to still more regular and systematized exercises, 
in the shape of such kindergarten occupations as building with 
cubes, stick-laying, bead-threading, pricking outlines, knotting 
and looping, paper cutting and folding ; and these, in turn, 
are superseded by clay- modelling, macrame work, knitting 
and darning, and finally by definite technical instruction in 
wood-carving, carpentry, basket-weaving, mat-making, needle- 
work, laundry work, and dressmaking, etc. Coincidently, 
speech is cultivated, instruction is given in the three R's, and 
every care is taken to repress injurious propensities and to 
develop moral character. 

The general principles of education do not differ from those 
in the case of the mentally normal, the difference being merely 
one of method and application. The whole object of the 
teacher is to reduce the environment of the child to a form 
which the deficiency of his mind is capable of assimilating, at the 
same time taking care that his mental pabulum is administered 
in an attractive shape. It may safely be said that no success 
will be attained unless the child's interest is aroused, and this 
must be the teacher's first care. It is by means of this interest 
and its progressive expansion, by gradually leading him step 
by step from one acquirement to another, that the capacity 
of the child is unfolded and that his education is accomplished. 
In many cases even destructive tendencies, where the child 
will do nothing but tear into pieces everything given to him, 
may be made use of as the first stepping-stone to manual work. 
Above all, it is necessary to remember that these children's 
conception of the abstract is extremely limited, that every- 
thing must be presented in the concrete, and that they will 
learn far more with their hands than with their heads. 

22 



/ 



338 Mental Deficiency 

It is necessary to pay particular attention to the cultivation 
of the sensory and motor functions. In the ordinary child these 
are perfected as the result of his own initiative, but in the anient 
special stimulation is required — not only because of the presence, 
in a considerable proportion of these children, of defects and 
irregularities of nerve action (abnormal nerve signs), which 
must be corrected before useful manual work can be accom- 
plished, but because such training affords a most valuable 
means of developing and co-ordinating intellectual activity. 

Thus, by means of suitable impressions through eye, ear, skin, 
muscle, nose, and mouth, the range and delicacy of the sensorium 
is increased, the brain rendered more receptive, the power of 
discrimination, as well as motor response, encouraged, and a 
basis supplied for future thoughts and ideas. We live, of course, 
in a perfect sea of sights, sounds, and vibrations of every kind, 
and, as already remarked, the healthy brain is so constituted 
that it can utilize these without any special tutorial help. I 
do not say that this is likely to lead to an optimum result ; in 
fact, I believe that the mental capacity of even the healthy 
child would be greatly improved by a course of sensory training 
on physiological lines. It is doubtful whether the mental 
development of anyone, even the best, comes up to the inherent 
possibilities. In the case of the defective mind, however, such a 
course of training is usually absolutely necessary, and constitutes 
a most important part of education. 

Similarly with regard to the motor system. All mental 
action is expressed by movement, or inhibition of movement, 
of some kind or other. It may be the mere opposition of the 
thumb and forefinger, the play of facial expression, the com- 
plicated mechanism of speech, or the deliberate conformation 
of the whole being to some emotion or ideal, as seen in conduct 
and behaviour. Since it is by the character of his movements 
and actions and general behaviour that the entire relationship 
of the mentally deficient child to the rest of society will be 
determined, it is plain that the development of the motor system 
is of the greatest importance. We may, indeed, say that all 
means for the cultivation of mental faculty are of importance 
according as they develop, co-ordinate, and control mental 
manifestations — i.e., movements. 



Treatment and Training 339 

Such, then, are the general principles upon which the educa- 
tion of the mentally deficient child must be based, and of which 
some further details will be given presently. It is obvious, 
however, that, although we must be guided by these principles, 
the measure of success achievable will vary enormously, and 
will be dependent upon the degree of initial defect — or perhaps 
I should rather say upon the inherent capacity for development 
present in any particular case. This cannot be foretold ; but 
undoubtedly there is a limit, and a point is at last reached 
beyond which no further advance takes place. 

In the idiots we shall get no farther than the implanting of 
habits of cleanliness, the development of some capacity for self- 
feeding and self-help, the curtailing of destructive and vicious 
propensities, and the expression, by signs or words, of simple 
wants. And we may not get even so far as this. In the 
imbeciles a higher stage will be attainable, and not only may 
they be made to be much more self-helpful and less dependent, 
but they may even be taught to perform a certain amount of 
useful routine work. Lastly, in the case of the feeble-minded 
the result achieved may be very considerable. A goodly number 
will become orderly, industrious, and well-behaved individuals, 
perhaps able to read and write a little, to do simple sums, and 
capable of performing useful work, which will at the same time 
keep them happily engaged and, where necessary, contribute 
to their support. But care will never take place. 

We may now refer to some points regarding the application 
of these principles to home and school training. 



Home Training. 

The training of the mentally deficient child should begin 
at birth, or as soon as the condition is diagnosed. The ament, 
even more than the normal child, rapidly develops bad habits, 
and care in the early years of life may not only do much to prevent 
these, but will be of the greatest assistance in paving the way 
for the more systematic training of after-years. This early 
training must of necessity be carried out at home, and, where 
circumstances permit, it is advisable that it should be at the 
hands of a trained governess ; but where this is not possible 

22 — 2 



34° Mental Deficiency- 

it must be undertaken by the parents. In any case, the growth 
and well-being of the child's mind, as well as body, should be 
under the general supervision of the medical attendant. 

I have already emphasized the necessity for telling the parents 
the truth regarding the condition of their child ; I would here 
remark that it is also the physician's duty to state plainly that 
neglect at this time may mean the development of habits which 
it may take years to eradicate, whilst care, kindness, and, above 
all, patience, will certainly result in improvement. Suitable 
food, clothing, warmth, exercise, fresh air, regular bathing — in 
fact, attention to all concerning the general bodily health — are 
of the first importance, whilst the habit of cleanliness cannot 
be enforced too early. Its acquirement in all but the most 
degraded idiots is usually only a matter of patience. With regard 
to training, there is no need for anything elaborate ; but the 
practice of relegating these children to out-of-the-way corners, 
and of depriving them of those adjuncts to development which 
they need far more than do ordinary children, is one which 
cannot be too strongly condemned. What is required at this 
time is a little more, and not a little less, care and patience. 
The child must be talked to and encouraged to play. If destruc- 
tive, it must be gently but firmly repressed. If inactive, its 
little hands must be made to feel the contact of toys, its sight 
stimulated by brightly coloured balls, and its hearing by music, 
or even noise. Instead of depriving it of toys, let it have an 
abundance to see and handle, and even to break. As it gets 
older, encourage it to sit up, to stand, and to walk, and do all 
that is possible to develop and co-ordinate sensory and motor 
activity. If the child is to be rescued from its solitary position, 
the time so spent will not be wasted. 

I think one of the most deplorable things in connexion with 
these unfortunate children is the neglect which so often attaches 
to their early home life. I do not think that this arises from 
unkindness, for I have often been struck by the manifest solici- 
tude of parents and all those about them. It is simply a matter 
of sheer ignorance as to what to do and how to do it, but it 
often results in the development of habits which are ineradicable. 



Treatment and Training 341 

School Training. 

Where the home conditions are such that adequate training 
cannot be obtained, or when such training no longer suffices for 
the needs of the child, he should be removed to a special training 
institution. Usually this is about the sixth or seventh year, but 
in certain circumstances it may be advantageous to remove the 
child earlier, whilst in others he may stay at home until a later 
age than this. The milder defectives — i.e., mentally deficient 
children who are not imbeciles — come within the operation of the 
Education Act at seven years, and may then be compelled to 
attend special classes or schools, if such exist. 

School training consists of more systematized methods, having 
for their object the development of the sensory, motor, intel- 
lectual, and moral faculties of the child. It is necessarily less 
individual than the training he has, or should have, received at 
home ; but this defect is more than compensated for by the 
spirit of emulation and of companionship which results from 
association with other children like himself. Moreover, although 
children in institutions must of necessity be taught in classes, it 
is still possible, by carefully grading and seeing that such classes 
are not too large, to ensure for each child a sufficient amount of 
individual attention. The regulations of the Board of Educa- 
tion require at least one teacher to every twenty defective 
children, but in lower-grade aments the proportion of children 
must be very much reduced. 

As we have seen in previous chapters, aments, with regard to 
the type of their nervous constitution, are divisible into two main 
groups. On the one hand there are those who are passive, inert, 
and markedly deficient in spontaneity ; on the other there are 
those who are restless and exceedingly motile, full of " tricks," 
" habits," and impulsive acts, and markedly deficient in the 
power of sustained attention. In each of these the training is in 
accordance with the general physiological principles which have 
already been alluded to — namely, stimulation through the sensory 
channels — but the method is different in the two classes. The 
stolid group, whose main defect is one of excitability, require 
stimulation by means of romping games, musical drill, and 



342 Mental Deficiency 

vigorous impressions of all kinds. The restless and excitable 
class, on the other hand, require their excessive movements to 
be brought under the control of the will by deliberate and syste- 
matic exercises, such as are comprised in many of the kinder- 
garten occupations. But apart from these broad differences, 
mentally deficient children differ enormously in their power of 
response as well as in the presence of particular defects or irregu- 
larities of brain function, and it is the duty of the physician in 
charge to make a careful examination of each child, and to 
advise the teacher regarding the appropriate method of training. 
Individual teaching must still be the keynote, and the teacher 
must ever be on his guard against neglecting the laggards for 
the sake of those of more promise. 

Teaching is an art which cannot be taught. It must come by 
practical experience of the management of children. The fol- 
lowing brief account simply aims at suggesting some of the chief 
physiological methods upon which training should proceed. The 
teacher with a love for his work and his pupils will have no 
difficulty in adapting, modifying, or extending these to suit the 
needs of any particular child, always bearing in mind that the 
chief requirements are the development of what is defective and 
the elimination of what is faulty. 

The Training of the Senses. — The chief sensory organs through 
which impressions reach the brain are six in number — namely, 
eye, ear, nose, mouth, skin, and muscle. Probably the training 
of the first and last of these are of most importance. 

By means of vision, information is gained regarding the colour, 
size, and form of objects, and attention should be given to each 
of these. It will often be found that, whilst the high-grade ament 
distinguishes the primary colours readily enough, he is unable to 
separate their shades ; and that, whilst he distinguishes between 
the form of a triangle, a square, and a circle, he fails to see any 
difference between triangular or quadrangular figures of varying 
shape. 

For teaching colour discrimination, a very convenient apparatus 
is a series of cardboard tables, each i inch square, and of 
a different shade. We may have six or eight shades of each 
of the colours blue, red, green, yellow, orange, and purple. It 
is unnecessary that the child should know the names, all 



Treatment and Training 343 

that he is wanted to do being to separate the collection of 
tablets into heaps according to their shade. Subsequently he 
may be taught their names. Coloured beads or wools may be 
made use of in the same way, and as the child progresses he will 
find great delight in pointing out to the teachers the different 
colours in pictures which are shown to him. Later on the 
kaleidoscope may be turned to profitable account in the develop- 
ment of colour discrimination. 

For cultivating the child's perception of form and size, it is 
first of all necessary to draw his attention to the coarse differ- 
ences in the many objects of common use. After this we may 
make use of a similar series of tablets of various sizes and shapes, / 
but of uniform colour, again getting him to divide them into 
heaps. " Size," " form," and " peg " boards, as well as the 
ordinary dissected puzzles of the toy-shops, not only afford 
valuable visual training, but are also of great use in developing 
tactile sense and in aiding muscular co-ordination. 

The cultivation of the tactile and muscle senses is particularly 
called for in the case of mentally deficient children, since, in addi- 
tion to its general educational value, these are functions which 
are absolutely essential for the proper performance of manual 
occupations, and the future of the ament must depend to a very 
great extent upon how he can use his hands. 

Sensations travel to the brain from the muscles just the same 
as from eye, ear, nose, etc., and with a little practice they may 
be appreciated and compared with one another in precisely the 
same way. These sensations arise in two ways : First, when a 
muscle or series of muscles is moved ; secondly, during the tension 
of a muscle. Generally speaking, impressions arising during 
muscular contraction are of use in appreciating size and distance, 
whilst those coming from muscular tension tell us of weight. 
Of course, in the actions of ordinary life we make use of several 
senses simultaneously, and those from muscle are aided by others 
from skin and eye. In training, however, it will usually be 
found advantageous for the pupil's eyes to be kept closed during 
these exercises. 

In the inert, unresponsive type of aments, we may have to 
stimulate the sensorium by passive movements of the limbs, or by 
compelling the hands to grasp, to feel, and to let go objects of 



344 Mental Deficiency 

different texture, temperature, density, and coarseness or smooth- 
ness of surface. In the restless and abnormally motile type, con- 
trol, co-ordination, and attention will be improved by blindfolding 
the child, and getting him to differentiate between form and size 
tablets by passing his fingers round their edge. Many mild 
imbeciles will enter with zest into the game of guessing articles 
in a bag by simply feeling them. Another excellent method is 
that recommended by Dr. Warner. It consists in accustoming 
the child to differentiate between varying weights of shot con- 
tained in a small chip-box held upon the extended palm. Miss 
Mumbray, who has had a large practical experience of the 
training of mentally defective children, is in the habit of 
directing her pupils to measure off on a sheet of paper a 
series of prescribed distances — say from J inch to 4 or 6 inches. 
After a little practice at this they are required to draw lines 
of specified length without the measure. In this exercise the 
ocular as well as the finger movements are utilized, and the 
results are not only extremely good in themselves, but are of 
the greatest value in leading up to kindergarten occupations, 
Sloyd, and subsequently industrial training. 

It occasionally happens that, instead of sensation being dimin- 
ished, it is so much increased as to become a source of pain. The 
hyperaesthetic hands must then be employed in rough, coarse 
work until their sensibility is dulled. 

Hearing is often defective in aments, but many of these children 
are thought to be deaf when the real deficiency is one of spon- 
taneous attention. The best means of developing this faculty 
is by music. Singing, musical drill, and the concerts of the 
entertainment-hall, which should form part of the life of all 
institutions, not only develop the child's power of attention and 
the range and accuracy of his hearing, but are a source of the 
greatest happiness. 

Where the senses of taste and smell are in need of special culti- 
vation, this may be accomplished by placing upon the tongue such 
substances as sugar, quinine, salt, chlorate of potash, soda, etc., or 
by getting him to sniff coffee, cocoa, snuff, or various essential oils. 

The Training of Movement. — It is impossible to overrate the 
importance of this. The mentally deficient child who has been 
taught to walk, to speak, and to dress and feed himself, has 



Treatment and Training 345 

obviously been materially benefited — still more so is this the case, 
however, when patient and systematic training has enabled him 
to put his hands to some useful occupation. But a higher result 
even has been achieved. Mental action and motor activity go 
hand-in-hand, and in the development of muscular co-ordination 
lies one of our best means of cultivating self-control and regularity 
of mental action. 

The training of movement in the mentally deficient resolves 
itself into three processes : (1) the development of action, (2) its 
co-ordination, (3) the correction of motor anomalies in the form 
of tricks and habits. These two latter are accomplished by the 
same means. Speech is also a motor phenomenon, but it will 
be convenient to refer to it separately. 

The Development of Movement. — As we have seen, a propor- 
tion of aments are listless, torpid, and inactive. They are quite 
content to sit still and do nothing, and they even evince no 
interest in the games of their companions. This condition is 
usually the result of a general sluggishness of the nervous system, 
but it is occasionally caused by nervous exhaustion due to ill- 
health. In the latter, rest, food, and fresh air are necessary ; in 
the former, active and vigorous stimulation is required. 

The only means of stimulating the motor cells of such a child 
is through the sensory pathways, and these we must endeavour 
to excite by every possible device. The child must be talked to ; 
his attention must be attracted by brightly coloured objects ; 
he may be bombarded with small flannel bags filled with beans, 
until he holds up his hands to protect himself, and eventually 
assumes the offensive ; he must be made to listen to and join 
in the romping, singing and drilling of the class ; by any means 
he must be made to move, and until this has been accomplished 
systematic lessons are quite out of place. 

The Co-ordination of Movement. — With the development of 
movement, its co-ordination must be attended to. In the healthy 
child this takes place naturally through the constant repeti- 
tion induced by its own initiative. " Practice makes perfect." 
In the ament the nervous discharge is irregular, and the 
harmonious adaptation of the motor response to the sensory 
stimuli, so that an optimum result follows a minimum expendi- 
ture, is slowly and laboriously acquired. 



346 Mental Deficiency 

Co-ordination is more readily developed in the case of a few 
large muscles, such as those concerned in standing, walking, and 
pushing, than in the twenty odd small muscles of the hand or in 
the intricate muscular apparatus concerned in speech. Conse- 
quently, the first exercises must be directed towards teaching the 
child to maintain a proper balance of the body, to run and to 
walk, to push and pull, to seize, to hold, and to let go, tolerably 
large objects. For this purpose such exercises as mounting a 
ladder placed against a wall, walking between the rungs of a 
ladder placed flat upon the ground, marching in, out, and over 
various obstacles to the accompaniment of music, and accurately 
covering with the feet a series of footprints chalked upon the 
ground, as recommended by Seguin, are of the highest service. 

At a later stage finer movements of the trunk and limbs may 
be attended to, and here games with a ball (such as cricket, foot- 
ball, and rounders), free exercises, musical drill, dumb-bells, and 
breathing exercises, find their place. The daily occupations of 
dressing and feeding, particularly the management of the spoon, 
afford most valuable fields of instruction. In milder cases, 
definite " eye-drill " may be given. 

Lastly, manual dexterity must be developed by the kinder- 
garten occupations, writing, drawing, cutting-out, paper-folding, 
clay-modelling, and the like. The imitation and transfer move- 
ments of Warner may here be utilized in some of the mildest 
cases.* Dr. Warner, in fact, regards them as " far more educa- 
tive than clay-modelling, drawing, and other child occupations." 
Theoretically this is so, but it is possible for an educational 
method, as for an article of food, to be so concentrated as to be 
inappetizing ; and these exercises have the disadvantage of being 
somewhat uninteresting, and of requiring an amount of atten- 
tion of which the mentally defective child is often incapable. 
In the training of these children interest is everything. 

The correction of irregular movements in the form of athetosis, 
" tricks," or " habits," is accomplished by the same methods as 
those used to develop co-ordination. Where the abnormality is 
chiefly in the hands, the kindergarten occupations, or in coarser 

* See an interesting paper by Dr. Warner on " The Training of the 
Intelligence through the Hand," read at the annual meeting of the Sloyd 
Association, 1902. 



Treatment and Training 347 

cases the peg-board, will be found of great service. This latter 
is a flat rectangular board drilled with holes of varying size, into 
which corresponding pegs are to be fitted. Where the motor 
irregularity concerns the face or trunk, facial and bodily gym- 
nastics are indicated. 

The Training of the Intelligence. — No means exist, or ever will 
exist, by which we can supply intelligence to the mentally defi- / 
cient. Each of these children has a certain capacity for develop- 
ment, which it is the object of training to educate, or " lead out," 
and which in the absence of appropriate training would remain 
undeveloped. To a very considerable extent this is accom- 
plished, as already remarked, by systematic exercises stimulating 
the receptive and perceptive faculties, and developing, controlling, 
and correcting the motor response. In the present section I pro- 
pose briefly to refer to some of the principles underlying more 
direct appeals to the intelligence, and here we shall also con- 
sider reading, writing, and speech. These methods, of course, 
are only applicable to the milder degrees of mental deficiency. 

One of the commonest and most important defects occurring 
in these children concerns the faculty of attention. In children 
of the inert, placid type, spontaneous attention is often lacking, 
and the child remains unmoved and indifferent, whatever happens. 
This condition results from a diminished nervous excitability, 
and it is remedied by a vigorous bombardment of the sensorium 
through every afferent pathway. On the other hand, the rest- 
less, unduly motile, hyperexcitable type are usually characterized 
by a want of voluntary attention and "concentration. Though 
seemingly so vivacious, they can settle down to nothing, and 
almost every conscious sensation or every thought distracts 
them from their task. The only way in which concentration 
and useful work can here be obtained is by presenting the child 
with something which is interesting. In fact, the keynote to 
attention is interest, and the psychological principles for develop- 
ing the power of attention may be expressed in the following 
three maxims : First, the pupil's occupations must be those in 
which he has an interest naturally (and it may be remarked that 
the child whom nothing will attract is in a very parlous state) ; 
secondly, his interest must be enlarged by the introduction of 
new occupations closely allied to, and leading out of, those in 



348 Mental Deficiency 

which he is naturally interested ; thirdly, an artificial or derived 
interest must be created for those subjects which are not attrac- 
tive in themselves, or, as Ribot says, they must be " rendered 
attractive by artifice." Rewards of various kinds form useful 
attractions. 

The process of association is of paramount importance in 
mental action. By its means all the varying impressions received 
through the senses are again connected, so as to produce a com- 
plex picture or a sequence of ideas. Defective power of associa- 
tion means not only crudeness of the individual mental images, 
but often paucity of images and ideas generally. In training this 
function, the method is the opposite of that employed in teaching 
discrimination. There sensations were presented singly, here 
they are presented simultaneously ; the law of association being 
that impressions which are simultaneously received by the brain 
tend to acquire functional connexions. For example, let the 
child handle, bite, note the form and colour and learn the name 
of, a shilling. The subsequent auditory sensation " shilling " 
will call up a mental picture composed of its associates. Object- 
lessons are also of great value in training association. 

Memory is largely dependent upon the power of association, 
and in proportion as we develop this so we cultivate memory. 
It is very useful to encourage the child's power of recall by getting 
him to give an account of the things seen or done upon returning 
from a walk or at the end of the day. Exercises in repeating 
poetry, quotations, and the like, help the child to remember the 
particular things repeated, but it is a mistake to imagine that 
they do anything towards cultivating the "faculty" of memory 
in general. 

The capacity for forming thoughts, judging and reasoning, is 
best stimulated and encouraged by individual contact with 
that teacher who knows how to present to the deficient mind in 
an easily assimilable form the simple facts of nature and every- 
day life. What are called object-lessons are here of the greatest 
value, but their value consists, not so much in the matter, as the 
manner in which they are presented. A good teacher will know 
how to turn almost anything to account, although most benefit 
will result from those objects in which the child has a natural 
interest. It is of the highest importance that he should be care- 



Treatment and Training 349 

fully questioned and encouraged to ask questions, and the 
teacher must ensure that everything is in the concrete, and that 
the ideas presented to the child have their visible, tangible, and 
material counterparts. 

Speech. — The mechanism concerned in speech, and the chief 
anomalies present in the mentally deficient, have been described 
in a previous chapter. In some of these children speech is 
absent in consequence of a lesion of the motor centre, and these 
cases are probably incurable. In others intractable deafness is 
the cause, and then occasionally (but very occasionally where 
mental defect is present), speech may be acquired by means of 
lip imitation. Other children of 'the lower grades apparently 
never speak because they have no ideas to express, or because 
it is easier for them to voice their feelings by grunts, screeches, 
and inarticulate noises. In the majority of the milder aments, 
however, there is some ability to speak, but speech is faulty and 
imperfect in consequence of conditions which, if not entirely 
curable, are at least in great part ameliorable by treatment. 

There are two chief causes of these defects : First, anatomical 
abnormalities of the end-organs concerned in speech-production 
or in the perception of sounds ; secondly, deficient muscular 
action and inco-ordination. The former of these consist of 
adenoids, enlarged tonsils, cleft palate, suppurating otitis, etc., 
and are chiefly responsible for thickness, indistinctness, and 
alterations of tone. These must be attended to by the surgeon 
before systematic instruction is attempted. Muscular inco- 
ordination gives rise to stammering, stuttering, inability to 
pronounce certain consonants, and the habit of substituting easy 
sounds for those which are difficult. The essence of speech 
training consists in discovering the nature and cause of the 
particular faults, and remedying them by the appropriate 
methods. 

Where muscular action is defective, which may be but part of 
a general inertia as seen in the stolid type of aments, it may be 
cultivated by encouraging the child to make use of his lips and 
tongue in blowing a toy trumpet or whistle. But in cases where 
muscular inco-ordination is the chief fault this is unnecessary, 
although such children, including stutterers and stammerers, 
will be benefited by a course of lip and tongue gymnastics and 



350 Mental Deficiency 

breathing exercises. In many cases where the faculty of speech 
lingers music is a great help. As Dr. Shuttle worth says, 
" Such children will frequently hum tunes that take their fancy 
before they are able to articulate words ; but if attractive tunes 
set to words containing repetitions of simple sounds (such as the 
' Ba-ba, black sheep,' of our old nursery rhymes) are constantly 
repeated to them, the probability is that, after a time, first one 
word and then another will be taken up by the pupil, till the 
rhyme as well as the tune is known." 

In cases of slurring, word-clipping, and consonantal defects, 
the fault generally lies in a want of synergic action, and the 
only remedy is for the teacher to demonstrate with his own 
articulatory apparatus how the defective sound should be pro- 
duced, until the child is able to imitate it. This requires con- 
siderable patience of both teacher and pupil, and it is essential 
that the latter should carefully watch the teacher's mouth and 
lips the while. It is useful to remember that many consonants 
which cannot be pronounced at the beginning of a word can be 
produced in the middle, and thus the desired sound may often be 
forthcoming if it is preceded by one the child knows. 

Writing naturally follows speech, and the first steps consist 
in the making of strokes upon the ruled slate. Much of the diffi- 
culty experienced by defective children is the result of imperfect 
co-ordination, which only practice and patience will overcome, 
and many of the imbeciles never do overcome it. In any case 
it will be necessary for the teacher to guide the child's hand in 
his initial attempts at making vertical, horizontal, and oblique 
lines, and this may have to be kept up for weeks. Some children 
learn to make rough drawings more easily than to write, probably 
because the task is more interesting, and the practice of tracing 
pictures which underlie a piece of framed frosted glass is some- 
times of assistance to writing. The imbecile who, after repeated 
coaxing, is unable to make any attempt at tracing, and whose 
only result is a meaningless scribble, is probably incapable of 
being taught. 

Reading. — Few imbeciles acquire the power of reading, but 
the majority of the feeble-minded, as a result of years of training, 
learn to read books of simple words and short sentences. Many 
of the higher types, indeed, become good readers. Probably 



Treatment and Training 351 

the best method of teaching is the word method, in which short 
words are read " at sight " before any attempt is made to teach 
the alphabet ; but time and patience rather than any particular 
method are the chief essentials. 

Arithmetic. — Number is usually a great stumbling-block to 
aments, although there are some feeble-minded persons who 
have an extraordinary affection for dates, and occasionally ability 
to calculate. The reason of their difficulty seems to be their 
inability to appreciate the abstract, and it is essential, in teaching 
number, that concrete examples should always be made use of. 
This is done by means of beads, counters, the abacus, or by 
graduated wooden rods. The cultivation of the child's faculty of 
discriminating size and weight through his muscle sense, in the 
manner previously described, is a useful prelude to teaching 
him number. An excellent form of concrete instruction is 
afforded by the " shop lesson." Having mastered the principles 
of addition and subtraction by means of actual objects, the less 
defective pupils may be initiated into the mystery of the 
numerical symbols, but progress with these will usually be very 
laborious. 

Industrial Training. 

Hitherto we have been concerned with the chief means by 
which the intellectual and nervous functions of the mentally 
deficient child may be stimulated and brought into orderly use — 
with education in its general sense. We now pass to technical 
instruction. It is not to be assumed, however, that the two are 
really separate, or that this latter has no educational value. On 
the contrary, technical or industrial training is not only a con- 
tinuation, and the natural outcome, of many occupations and 
exercises which have formed part of the general training ; but 
in itself it is of distinct educational value. It is a well-recognized 
fact that the mentally deficient child learns more with his hands 
than with his head ; whilst his future is far more a matter of 
manual than of mental dexterity. Industrial and technical 
training, therefore, is at once an educational factor of consider- 
able importance, as well as the only means of turning these 
unfortunate children to practical account. It has been shown 
that, as a result of this training, a considerable number of the 



V 



35 2 Mental Deficiency 

milder aments become capable of remunerative work ; and even 
where the social position is such that this is unnecessary, it is 
still of the greatest use in providing them with employment. 
The teaching of a definite occupation, then, should never be 
omitted, and should, if possible, be begun during childhood or 
adolescence. One cannot but feel that in many instances there 
is a tendency to allow school-training to go beyond its real 
purpose — that of cultivating intellectual and nervous action 
generally — and to make it too scholastic. 

The nature of the industrial training must be determined by 
the particular characteristics of the individual, regard being paid, 
of course, to sex and social position, and to the probable environ- 
ment in after-life. Where possible, an outdoor occupation should 
be selected, and particularly so in the case of those whose coarsely 
formed hands stand in the way of any manual dexterity — such, 
for instance, as the Mongolians. But care must be taken to 
protect those so engaged against the inclemency of the weather, 
and it must be remembered that there may be many days when 
this will absolutely prevent outdoor work. Gardening, whether of 
flowers, fruit, or market produce, is particularly suitable, and 
the child's taste for this may be developed, as well as a certain 
amount of useful information imparted, by practical object- 
lessons in growing seeds, plants, etc., in the schoolroom. The 
strong and sturdy type may be usefully employed in the dairy 
or on the farm. 

Where regular outdoor work is impossible, either on account of 
the physical condition of the patient or for lack of accommodation, 
there are many useful and remunerative indoor occupations which 
may be taught. Amongst these may be mentioned, for males, 
boot-making, tailoring, carpentry, basket-weaving, mat and brush 
making, chair-caning, book-binding, and such-like. For females 
there are cookery, laundry work, dressmaking, hand and machine 
sewing, knitting, and even embroidery and fine-art needlework. 
In all well-equipped institutions a considerable amount of the 
making, mending, and general domestic work of the establish- 
ment — even the printing — is performed by the inmates, under 
supervision. Instruction in these various occupations is, of 
course, given by skilled master hands. 



Treatment and Training 353 

Moral Training. 

The training of the child's moral or ethical sense is by no 
means the least important of the teacher's duties ; indeed, if this 
is not carefully attended to, the education of his intellect may 
simply result in an increased power for ill, and cause him to be, 
not merely useless, but actually dangerous to society. Moral 
education, therefore, forms an essential part of the home and 
school training of the mentally deficient child. It has for its / 
general object the repression of antisocial tendencies and the 
inculcation of habits or principles which will enable the child to 
adapt his conduct to the laws of his society and the well-being 
of his fellow-creatures. It is entirely removed from, and, from 
the physician's standpoint, is of greater importance than, religious 
education. If the condition of the child permits, the elementary 
principles of a religious doctrine may be added, and in some cases 
Christian ideals may exert a considerable effect upon the moral 
behaviour. The question of religious education, however, is the 
domain of the ecclesiastic, and beyond the scope of this work. 

The bulk of aments are rather amoral than immoral, and their 
defect of ethical sense stands in the same relationship to that of 
the normal child as does their defect of general intelligence, 
requiring also special means for its development. There are, 
however, three types specially prone to the commission of 
immoral acts, and the training of these must be the object of 
particular care. 

These are, first, those who are readily induced to commit 
antisocial acts, at the instigation of unscrupulous persons, 
because of their extremely " facile " disposition. Impression- 
able, susceptible, and readily swayed, utterly incapable of with- 
standing the suggestions, good or bad, of their companions, the 
only safeguard is to keep them away from temptation, and to 
ensure that their social atmosphere shall be good. It is possible 
that in course of time this atmosphere may to some extent lead 
to the formation of an active moral sense, and that the persistent 
inculcation of moral precepts may make impressions capable of 
influencing their conduct ; but, in my opinion, this can never be 
relied upon, and the only safe course with regard to this class is 

23 



354 Mental Deficiency 

to keep them under permanent supervision. They are simple 
and confiding beings, and many of them are industrious workers. 

The second group consists of those persons whose nervous 
constitution is so unstable and explosive that the most trifling 
occurrence serves to produce a violent storm. In this they will 
commit a grave breach of discipline, an offence against law and 
society, or even a serious crime. The attacks in many ways 
resemble the motor storms of the epileptic ; in fact, the condi- 
tion may well be termed one of psychic epilepsy. In such cases 
some degree of control is frequently acquired as the result of 
regular occupation, careful supervision, and firm discipline. 
Medicinal treatment in the form of the bromides is often also a 
valuable adjunct, and by these means considerable improvement, 
or even cure, may be brought about. 

The third group consists of the so-called moral imbeciles. In 
these there seems to be an absolutely ineradicable propensity to 
the commission of every kind of offence, and these persons will 
lie, steal, burn, destroy, and assault, without being influenced in 
the slightest by persuasion, threat, or punishment of any descrip- 
tion. Again and again have I known the offence repeated almost 
whilst the words of contrition were hot upon the tongue. I 
believe that this condition is practically incurable, and that the 
only safeguard lies in strict and permanent detention. 

Passing now to the ordinary type, in which there is neither a 
specially facile disposition, a predisposition to emotional storms, 
nor deeply ingrained immoral and criminal tendencies, we have 
to consider the manner in which the latent ethical sense may be 
sufficiently developed to lead the child to shape his conduct in 
accordance with the manners and customs of good society. If 
this be not so developed, it is tolerably certain that the age of 
puberty, if not earlier, will see the assertion of many animal 
instincts which the weakened capacity of control will be power- 
less to overcome. 

It was stated by John Stuart Mill that the foundation of the 
moral principle lies in utility. The mentally normal child may 
be taught to be moral through a gradual recognition of this. By 
being made to suffer the natural consequences of his own breaches 
of discipline, he is gradually brought, through his intellect, to 
appreciate that virtue is attended with pleasurable, and vice and 



Treatment and Training 355 

wrongdoing with unpleasant, consequences. To a certain extent 
this may be made use of in the mentally deficient child, but his 
defect is often such that he cannot be made to appreciate the 
natural consequences, the utility or futility, of every act he com- 
mits, and this result can only be attained by a system of arbitrary 
rewards and punishments. 

There are many rewards for good conduct which appeal to 
these children. In the lower types the promise of a toy, a sweet- 
meat, or some little treat in the shape of an entertainment, will 
often prove a useful incentive to good behaviour. Many mentally 
defective school-children attach great value to the little card- 
board medal pinned upon their breast by the teacher, and at a 
later stage the commendation alone of the instructor to whom 
they have grown attached will suffice. Similarly with punish- 
ment. The deprivation of some favourite article of food, such 
as the withholding of pudding for dinner, the denial of the enter- 
tainment which the child's companions are allowed to enjoy, the 
reproof of the teacher — all these may be made use of to impress 
upon the child that wrongdoing is unpleasant, and that it is 
wisdom to be good. 

It is very important that the whole demeanour of the teacher 
should be kind and sympathetic, gentle but firm, and that all 
petting and spoiling should be rigorously avoided. Approbation, 
if earned, should be bestowed ungrudgingly, and will be found a 
powerful incentive to further progress and factor in moral train- 
ing. Disapprobation, if consistently expressed, is often equally 
efficacious as a deterrent. 

With regard to the infliction of corporal punishment opinions 
are somewhat divergent. My own feeling is that it should be 
avoided wherever possible. But in cases of wilful and flagrant 
breaches of discipline or open defiance of authority it is not only 
justifiable, but beneficial ; in fact, it is often the only means by 
which the child may be taught that respect for others which is 
the essence of morality. 

In the task of implanting good habits and the developing of 
the ethical sense, the faculty of imitation, often so marked in 
these children, must never be lost sight of, since it may readily 
be turned to good or bad account. It is extraordinary how mild 
and gentle girls, brought up in an atmosphere of refinement and 

23—2 



356 Mental Deficiency 

care, will suddenly, and upon the slightest provocation, give vent 
to a torrent of the most disgusting and obscene abuse which they 
may have heard by chance on some solitary occasion. It is of 
the highest importance that the surroundings and the tone of 
mentally deficient persons should be well ordered from the very 
beginning, and there is no doubt that the home environment of 
early life exercises a most potent influence in after-years. We 
cannot expect these children to become affectionate, sympathetic, 
and generous unless these qualities are evident in the lives of 
those about them, and a rigorous censorship of the entire social 
atmosphere, even with regard to pictures and entertainments, is 
an absolute necessity. If we are to ensure truthfulness, honesty, 
and uprightness, it is essential that parents, teachers, and 
physician should be truthful, just, and straightforward in all 
their dealings with these children. Reward and punishment must 
be deliberate, and apportioned in such a manner as not only to 
fit the crime, but to establish its relationship in the mind of the 
child. Otherwise it will result in more harm than good, and will 
inevitably lead to a complete alienation of confidence and affec- 
tion. By the judicious imposition of punishment or reward which 
the child recognizes as being related to his fault or virtue, we 
shall be in no danger of losing his love and affection or violating 
his sense of justice. We shall develop, rather than perplex, 
his reasoning power, and we shall cultivate his moral sense and 
control just as we developed his intellectual capacity. 



CHAPTER XX 

CONCLUSION 

In the preceding pages we have attempted to give an account of 
the prevalence, causation, pathology, and clinical characteristics 
of amentia, as well as of the abilities and disabilities of persons 
suffering from this condition, and the manner in which their social 
relationship is thereby affected. There are a few matters arising 
out of this account to which we may refer in conclusion. 

With regard to training, it might be argued — indeed, it is 
sometimes argued — that, since we can never cure these persons 
or make them really self-dependent, the expenditure of time 
and money upon their education is unjustifiable. This is a 
fallacy. I fully recognize that we must avoid the danger of their 
training becoming a fashionable fad, and being carried to an 
extent out of all proportion to the results likely to be achieved — 
that, in fact, not only must the ament be sheltered from the 
neglect or adverse competition of society, but that society and 
the ratepayer must be protected against the ament. I believe, 
however, that both these ends are best attained by suitable 
training, and that the withholding of such is not only injurious 
to the individual ament, but constitutes a danger to the State ; 
moreover, it is an economic blunder. 

It has been shown that a considerable number of these persons 
possess habits and propensities which render them a decided 
menace to society. These are partly inborn, but they are also 
to a great extent the result of neglect, and there can be no 
doubt that judicious and systematic training would do much to 
prevent their development. I do not say that such training 
would entirely prevent crime and insanity in these persons, but 

357 



358 Mental Deficiency 

I do think that it would do very much to diminish these 
conditions. 

But education not only results in a lessening of evil ; it is 
attended with a positive good. Although self-dependence may 
never be attained, it has now been amply shown that, in con- 
sequence of proper training, a considerable proportion of the 
milder aments become capable of useful and remunerative 
work. In the case even of persons of good social position, this 
is a decided advantage ; for employment adds greatly to their 
happiness, as well as diminishes their possibilities for mischief ; 
whilst in the case of persons whose circumstances are such that 
they must be supported by the public, this is an economic 
consideration of great importance. 

Many imbeciles, even, may be trained to help in the routine 
work of the institution or home, whilst in the idiots the power of 
self-help and cleanliness which may by this means be acquired is 
not to be despised. 

These facts are now generally recognized, and there are few 
civilized countries entirely lacking in laws and institutions for 
the training of the mentally deficient. It must be admitted, 
however, that in many cases the accommodation provided falls 
short of the demand, and in this country it is at present woefully 
inadequate. 

But training alone is not sufficient. No one, of course, would 
expect an idiot or imbecile to be capable of taking care of himself ;/ 
but a large number of people do think that the merely feeble- 
minded youth or girl — the educated product of the special school 
— ought to be able to do so, and the neglect, accordingly, to sub- 
sequently provide adequate supervision or after-care often results 
in a complete undoing of all the good that has been done. 

The fact is, that although training will certainly do much 
to repress the growth of vicious, criminal, and insane ten- • 
dencies, and will render the mildest grades of defect capable of 
remunerative employment, or even of earning a living, this 
can only be so " under favourable circumstances/' Competition 
with the normal population is impossible, and, as a result of 
the Workmen's Compensation and Employers' Liability Acts, 
employment is becoming more and more difficult to obtain 
for these persons. Not only must work suited to their capacity / 



Conclusion 359 

be found for them, but in the great majority of cases the wages 
so earned must be laid out, and a general supervision exercised 
over their whole behaviour, just as in the case of children. 
Provided this be done, the time and money spent on training 
will be well repaid, and will result in the transformation of 
useless, and even dangerous, individuals into useful, happy, and 
contented members of society. Failing this supervision, how- 
ever, aments, whether trained or otherwise, will certainly de- 
generate, and will inevitably swell the population of our asylums, 
prisons, and workhouses. In the case of females, it is tolerably 
certain that even before this can happen the blight will have 
been passed on to a new generation. 

The question arises as to what form this supervision should 
take. At present, as we have seen, the majority of feeble- 
minded persons in this country, who are not at home, where 
often the supervision is far from adequate, are (excluding 
criminals and lunatics) resident in workhouses or in charitable 
institutions of various kinds. In each of these cases there is the 
grave disadvantage that detention cannot be enforced, but is 
entirely subject to the will of the patient ; the majority of 
workhouses suffer from the additional disadvantage that they 
provide no remunerative or systematic employment. 

It would be beyond the purpose of this work to enter into any 
discussion on this matter, and undoubtedly the nature of the 
provision must vary with, and be dependent upon, the habits, 
propensities, capacity, and character of the individual. Any 
method of administration which does not take these into account, 
and which attempts to provide for mental defect in the abstract, 
cannot be an economic success. Briefly, we may say that to be 
satisfactory the provision for each individual must be of such a 
nature as to (1) adequately safeguard the interests of society 
against the special peculiarities of^ the ament ; (2) project the 
ament against the evil suggestions and pernicious influence of 
certain sections of society, and at the same time ensure him 
kindly treatment ; (3) utilize his working capacity to the fullest 
and most remunerative extent, so that the cost of provision 
falls as lightly as possible upon an already overburdened rate- 
payer. In general, these three conditions will best be fulfilled 
by compulsory detention in suitable colonies or institutions. 



360 Mental Deficiency 

With regard to the prevention of propagation by these persons, 
two methods have been proposed — namely, the restriction of 
their marriage, and their sterilization by operation. 

In America, sterilization or asexualization has been performed 
upon some hundreds of patients, both male and female, and it is 
contended that this method has an additional advantage in that, 
by its means, many depraved habits and bestial propensities 
have been cured and the general behaviour much improved. 
But it can never take the place of segregation, and it is a 
method which is at present decidedly repugnant to English 
feeling. My own opinion is that, given proper training, followed 
by adequate supervision, it should rarely be necessary. Where, 
in the judgment of the physician, it is definitely indicated, and 
likely to be attended with advantage to the patient, I do not 
think the parents or guardians would withhold their consent ; 
but it is a grave matter to advocate its legalization for any and 
every case of mental deficiency. 

The question of marriage is, of course, one of very great import- 
ance, not only as applying to those who are actually mentally 
deficient, but in regard to those who, non-defective in themselves, 
are yet the descendants of a neuropathic or otherwise diseased 
stock, and likely to beget amentia or other morbid mental and 
physical conditions. 

There are some persons of whom it may be said with certainty 
that they will transmit disordered or enfeebled conditions of mind 
or body to their children ; such, of course, should never marry. 
Others, again, would probably only do so if conjoined to a person 
of like tendencies. In yet others a slight existing taint might, 
by suitable marriage, be diminished, and, with further selection, 
finally eradicated. Although it generally happens that the child 
bears a greater resemblance to one particular parent, it is never- 
theless a mixture of both, and this is one of Nature's means for 
bringing about modifications and variations in the human race. 
The result of any union is a step either in an upward or a down- 
ward direction. 

The effect upon any community of the continued propagation 
of the unfit is simply a question of mathematics. As soon as 
that stage is reached at which there is a preponderance of persons 
suffering from diminished moral, intellectual, and bodily vigour, 



Conclusion 361 

that community is inevitably doomed ; and history shows that 
this has repeatedly happened to the civilizations of the past, 
although Mankind undoubtedly continues, and will continue, to 
progress. Whether the account of Noah and the Ark be con- 
sidered literally true or not, it contains a world of meaning for 
the thoughtful student of human evolution. 

The importance of the question of marriage, therefore, and 
particularly the marriage of the " unfit," cannot be too strongly 
urged. It is far too often entered upon without any thought 
beyond the convenience or taste of the contracting parties, and, 
indeed, not always with even that amount of considera- 
tion ; but sooner or later we shall be compelled to consider its 
effect upon future generations. Considering the amount of 
attention which is bestowed upon the breeding of our horses, 
cattle, dogs, and even our vegetables, it is surely not too much 
to ask that a little thought should be given to the breeding of 
our race. 

In some of the States of America legislation towards this end 
has actually been adopted, the marriage of epileptic, imbecile, 
and feeble-minded persons being prohibited by law ; but what 
may be the practical effect of these regulations I have been 
unable to ascertain. 

I see no reason why such restrictions with regard to persons 
suffering from mental deficiency should not be made in this 
country, although at present they are hardly likely to be passed 
with reference to any less pronounced conditions. But the 
relation of the sexes cannot be entirely controlled in this com- 
pulsory way, and it seems to me that it is chiefly to the educa- 
tion of public opinion and the gradual development of the con- 
science of the community that we must look for improvement in 
this matter of the responsibilities attaching to marriage. The 
Church has peculiar opportunities of rendering incalculable 
service to future generations by pointing out the important 
issues of the marriage tie ; whilst it is at once the solemn duty 
and privilege of the Medical Profession to speak on this subject 
in authoritative and unmistakable terms. Unfortunately, the 
tendency of recent legislation has often been in a contrary 
direction. It has aimed at quantity rather than quality, and, 
by diminishing in many ways the responsibilities of parents for 



362 Mental Deficiency 

their offspring, it has certainly not contributed to the develop- 
ment of home life and of that grit and sturdy independence of 
character of which we English were formerly so proud. 

So long as we are content to raise no voice against the marriage 
of the diseased, trie degenerate, the criminal, and the pauper, and 
are willing to educate, feed, clothe, and ultimately pension as 
many offspring as these persons see fit to produce ; so long as 
legislation is permitted a free hand in doing everything calculated 
to diminish parental and social responsibility and to strike at 
the very root of any incentive to labour ; so long as our law- 
makers and would-be philanthropists are blind to the folly of 
transferring the burdens and penalties inevitably following care- 
lessness, improvidence, indifference, drunkenness, and unlimited 
selfishness, from the shoulders of those upon whom they should 
rightly fall to the careful, provident, and industrious members of 
the State : then so long will these classes (and these qualities) 
continue to be perpetuated, and their numerical ascendancy is 
simply a question of time. 

Finally, we have to consider how this disease may be prevented, 
and this can only be accomplished by dealing with its prime cause. 
The origin of mental disease is intimately connected with the 
origin of disease in general, but, as we have seen, there are certain 
factors which appear to have a particular influence in initiating 
that nervous instability whose final culmination is mental defect. 
To-day the chief of these are chronic alcoholism, tuberculosis, 
mental worry and anxiety, and the hurry and scurry, with all 
their attendant excesses and dissipations, of modern life. Pos- 
sibly in other ages other causes have predominated, but at any 
period they have been excesses of some kind or other which have 
entailed an undue demand upon the bodily structure. 

According, therefore, as we diligently seek out and conform 
to the laws of health, and as we improve the manner of living, 
the moral, mental, and physical fibre, and the general well-being 
of our people, so shall we be successful in preventing disease of 
the mind. 



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APPENDIX II 

METHOD OF ESTIMATING THE TOTAL NUMBER 
OF AMENTS IN ENGLAND AND WALES 

Although the local investigations of the Royal Commission of 
1904 only relate to eleven areas, having an aggregate popula- 
tion of 2,321,567, nevertheless, provided certain corrections 
are made, it is possible to calculate from these returns the 
total number of aments in England and Wales with tolerable 
accuracy. 

Two corrections are necessary, for the following reasons : 
(1) The areas investigated may not be a fair sample of the entire 
country ; (2) the returns do not include such aments as are 
certified under the Lunacy Acts. 

Correction I. — The only means of ascertaining whether the 
areas investigated are a fair sample of the whole country is to 
take some similar condition, the total incidence of which is 
known; the only one available being insanity. As remarked 
in Chapter II., there are slight differences in the relative inci- 
dence of amentia and insanity as a result of environment, 
but, on the whole the incidence of the one is directly propor- 
tionate to that of the other. Considering the close etiological 
relationship of these two conditions, I think we may assume 
that the same holds good throughout the country, or at all 
events sufficiently so for our present purpose. As we have seen 
(see p. 8), the incidence of insanity in the eleven areas examined 
is 3*15 per 1,000 population, whereas the incidence of insanity 
in England and Wales is 3*42 per 1,000 population. This can 
only be due to the fact that the eleven areas contain a relatively 
greater proportion of districts in which insanity (and conse- 

366 



Appendix II 367 

quently amentia) is of low incidence, the co-efficient of inci- 
dence being 

3*15 D 

Correction II. Aments Certified under the Lunacy Act. — A 
considerable number of idiots and imbeciles are detained in 
ordinary lunatic asylums, etc., and their number is very difficult 
to calculate, for the reason that the proportion varies in different 
localities. From the Report of the Lunacy Commissioners, 
which, however, does not give the actual figures, idiots and 
imbeciles would appear to comprise about 5 or 6 per cent, of the 
asylum population. I am convinced, however, that this estimate 
is much too low. From information kindly placed at my 
disposal by the medical superintendents of the asylums of 
Manchester, Birmingham, Somersetshire, Wiltshire, Carmarthen, 
and Northumberland, as well as from my own examination of 
a number of workhouses and the asylums of the London County 
Council, I have come to the conclusion that if the " notified 
insane " of the county and borough asylums, the Metropolitan 
District asylums, the workhouses, and the outdoor paupers, be 
considered in the aggregate, they will contain about 10 per cent, 
of idiots and imbeciles, in the proportion of one idiot to three 
imbeciles. The number of the above classes throughout the 
country is 112,702 ;* there are consequently 11,270 aments 
certified under the Lunacy Act. 

But this is not the whole of the certified aments. As a result 
of personal inquiries, I am of opinion that at least another 5 per 
cent, of the inmates of county and borough asylums are feeble- 
minded. Many of these owe their incarceration to epilepsy or 
insanity, but the real condition is mental deficiency, and I think 
that they should be classed with the aments rather than the 
insane. Their number may be stated approximately as 4,450. 

* The figures given in the Sixtieth Annual Report of the Lunacy Commis- 
sion are as follows : 

In county and borough asylums ... ... 89,342 

In workhouses ... ... ... ... 11,151 

In Metropolitan District asylums ... 6,591 

Outdoor paupers ... ... ... 5,618 

112,702 



368 Mental Deficiency 

Consequently the total number of aments in England and 
Wales is approximately as follows : 

Aments ascer- -\ 

tained in areas Pop. England and Wales, 

investigated. 1901. Coefficient of 

8,070 X 32,525,7l6 incidence. 

2,321,567 * ro85 = 122,809 



Uncertified. 



Pop. of areas. 

( Idiots and imbeciles. Feeble-minded. Certified. 1 

+ t 11,270 + 4,450 = 15,720/ 

= 138,529 Total Aments. 



It is necessary to point out that in the Report of the Royal 
Commission the total number of " mentally defective persons " 
(apart from certified lunatics) in England and Wales is estimated 
at 149,628. In making this calculation the Commissioners 
assume that the statistics ascertained regarding the districts 
investigated are applicable to England and Wales generally, and 
consequently their total estimate should be less, and not more, 
than that arrived at by myself. This increase in the estimate of 
the Royal Commission appears to be due to the inclusion of sane 
epileptics, and since, in my opinion, these should not be classed 
as aments, and since also I believe that the results of the local 
investigations are not strictly applicable to the whole country, I 
have thought it advisable to make an independent calculation. 
It will, of course, readily be understood that no calculation of 
this kind can be other than approximate, and even were a house 
to house visitation practicable it is doubtful whether the statistics 
would be absolutely accurate. 

With regard to the total number of aments in England and Wales 
who are urgently in need of provision at the present time (for reasons 
which have been stated on p. 286), there are, inclusive of feeble- 
minded (" mentally-defective ") children, according to my 
estimate 61,525, or, according to the estimate of the Royal 
Commission, 66,509. These numbers, again, are only approxi- 
mate, but they are sufficiently near for practical purposes. 

The areas in Scotland and Ireland which were investigated by 
the Royal Commission are not sufficiently numerous to enable 
a corresponding estimation to be made regarding those countries ; 



Appendix II 369 

it may be stated, however, that in Glasgow there were ascertained 
to be present 1,614 mental defectives, equivalent to 0*26 per 
1,000 population ; whilst in the four areas examined in Ireland 
there were 1,527 mental defectives, equivalent to 0*57 per 1,000 
population. But it is impossible to conclude that these figures 
are applicable to these countries as a whole, and, therefore, as the 
Commissioners remark, they are merely given for what they are 
worth. 



24 



APPENDIX III 

THE LAW OF ENGLAND CONCERNING AMENTIA 

The law of England regarding the care and control of persons 
suffering from amentia is at present very far from satisfactory. 
It was, in fact, to a great extent the recognition of this which led 
to the appointment of the Royal Commission of 1904, " to con- 
sider and report upon the existing methods of dealing with idiots 
and epileptics, and with imbecile, feeble-minded, or defective 
persons not certified under the lunacy laws." 

The Commissioners have now furnished their Report, and their 
conclusions and proposals are set forth in eighty-nine recom- 
mendations.* These are based upon a voluminous mass of 
evidence, a series of careful local investigations conducted by 
medical men, and the personal visits of several of the Com- 
missioners to institutions in America and on the Continent. 
The conclusions are formulated with conspicuous care and ability f 
and there can be no doubt that as a whole they are extremely 
sound, and that their adoption would do very much indeed to 
solve the pressing problem of the mentally deficient of this 
country. It is therefore earnestly to be hoped that the Legisla- 
ture will not long delay giving effect to them. 

In view of this report, the effect of which would be materially 
to alter the present methods of dealing with aments, I feel that 
any lengthy account of the law as it stands to-day is unnecessary. 
I shall therefore confine myself to a brief outline of the existing 
law and a short sketch of the main modifications proposed. 

* Report of the Royal Commission on the Care and Control of the 
Feeble-Minded, 1908. Vol. viii. 

370 



Appendix III 371 



The Present State of the Law. 

Idiots and Imbeciles. — " Idiots " come within the provisions of 
two statutes — viz., the Lunacy Act of 1890 and the Idiots Act 
of 1886. " Imbeciles " come within the latter only. 

1. According to the Lunacy Act of 1890 [53 Vict., ch. 5], 
" ' lunatic ' means an idiot or person of unsound mind ;" hence 
idiots may be certified and committed to care in precisely the 
same manner as " lunatics " as ordinarily understood. 

2. Under the Idiots Act of 1886 [49 and 50 Vict., ch. 25], " an 
idiot or imbecile from birth or from an early age may, if under 
age, be placed by his parents or guardians, or by any person 
undertaking and performing towards him the duties of a parent 
or guardian, and may lawfully be received into, and until of full 
age detained in, . any hospital, institution, or licensed house 
registered under this Act . . . upon the certificate in writing of a 
duly qualified medical practitioner." 

This certificate, which is accompanied by a statement of 
particulars signed by the parent or guardian, is in a prescribed 
form, and is to the effect that the person " is an idiot (or has been 
imbecile from birth, or for . . . years past, or from an early age) , 
and is capable of receiving benefit from [the institution (describing 
it)]." The person is, on this certificate, detained until he is of 
full age. If he has been so detained, he may, with the consent 
of the Commissioners in Lunacy, be retained after he is of full 
age. If, on the other hand, he be of full age at the time of 
application, he may be admitted on the same certificate and 
statement. 

All institutions for the care of idiots have to be registered by 
the Commissioners in Lunacy, and are inspected by them. They 
are educational and custodial, and admission is obtained by 
payment of fees by relatives or public bodies, by election through 
votes, or in some cases by a combination of both these methods. 

Idiots and imbeciles may also be taken into the workhouse, or 
receive outdoor relief from the Poor Law guardians ; not, how- 
ever, on the ground of their deficiency, but on account of being 
paupers, in precisely the same manner as may non-defective 
paupers. But the father of an idiot or imbecile child who is in 

24 — 2 



37 2 Mental Deficiency 

this way relieved by the Poor Law loses the Parliamentary 
franchise. 

Feeble-Minded Adults. — If a feeble-minded person cannot be 
certified as "of unsound mind " or " imbecile " under either of 
the preceding statutes, he is not, qua mental defect, amenable to 
any existing law. If insane, he may be committed to care in a 
lunatic asylum in precisely the same way as an ordinary lunatic. 
If a pauper, he may be granted indoor or outdoor relief by the 
Poor Law guardians on account of his pauperism. Or he may 
be found incapable of managing his affairs, and his property safe- 
guarded by proceedings in Chancery. There are, moreover, a 
number of voluntary homes and training establishments to which 
feeble-minded persons may be sent, and some of these homes are 
certified by the Local Government Board as institutions suitable 
for the reception of applicants sent by the Boards of Guardians. 
But there is no legal machinery by which feeble-minded persons 
may be detained in these establishments against their will. 

Feeble-Minded (" Mentally-Defective ") Children.— Under the 
Elementary Education (Defective and Epileptic Children) Act of 
1899 [62 and 63 Vict., ch. 32], the local education authorities are 
empowered (but not required) to make educational provision for 
" what children in their district, not being imbecile and not being 
merely dull or backward, are defective — that is to say, what 
children by reason of mental or physical defect are incapable of 
receiving proper benefit from the instruction in the ordinary 
public elementary schools, but are not incapable by reason of such 
defect of receiving benefit from instruction in such special classes 
or schools as are in this Act mentioned." 

Where this Act has been adopted and special classes or schools 
established, the attendance of feeble-minded children can be 
compelled between the ages of seven and sixteen years. After 
that age the education authority has no further jurisdiction. 
Where this Act has not been adopted and there are no special 
schools, the guardians may, if they see fit, place the child in such 
a school in another district, and maintain him there out of the 
rates. Up to September 30, 1906, the Act had been adopted by 
8y local education authorities in England and Wales, and on 
August 1, 1907, special accommodation existed for a total of 
9,082 children, of whom 4,946 were in London. The total number 



Appendix III 373 

of these feeble-minded children in England and Wales, it will be 
remembered, has been estimated at 50,665, thus leaving 41,583 
(or, according to the estimate of the Royal Commission, 35,662) 
at present unprovided for. 

Recommendations of the Royal Commission. 

The general tenor of the proposals of the Commissioners will 
be evident from the following summary of their " Principles 
Adopted in Dealing with the Problem of the Mentally Defective " : 

1. That persons who cannot take a part in the struggle of life 
owing to mental defect, whether they are described as lunatics, or 
persons of unsound mind, idiots, imbeciles, feeble-minded or 
otherwise, should be afforded by the State such special protection 
as may be suited to their needs. 

2. That the mental condition of these persons, and neither 
their poverty nor their crime, is the real ground of their claim 
for help from the State. 

3. That, if the mentally defective are to be properly considered 
and protected as such, it is necessary to ascertain who they are 
and where they are, and to bring them into relation with the 
local authority. 

4. That the protection of the mentally defective person, what- 
ever form it takes, should be continued as long as is necessary for 
his good. This is desirable, not only in his interest, but also in 
the interest of the community. It follows that the State should 
have authority to segregate and to detain mentally defective 
persons under proper conditions and limitations, and on their 
behalf to compel the payment of contributions from relations 
who are able to pay for their support ; or should itself provide 
such care and accommodation as may be necessary, either directly 
or through the local authority. 

5. In order to supervise local administration of this nature, a 
central authority is indispensable. 

6. That in regard to the protection of property all mentally 
defective persons should have like privileges. 

7. It is essential that there should be the closest co-operation 
between judicial and administrative authorities — in this case the 
Chancery Division of the High Court and the Central Authority. 



374 Mental Deficiency 

The manner in which it is proposed to apply the foregoing 
principles is briefly set forth in the following extracts from the 
Commissioners' Recommendations and Report : 

I. That there be one central authority — to be known as 
" The Board of Control" for the general protection and super- 
vision of mentally defective persons, and for the regulation of the 
provision made for their accommodation and maintenance, care, 
treatment, education, training, and control. 

[Recommendations I. and V.] 

II. That there be placed under the general protection and 
supervision of this central authority — 

(i) Persons of unsound mind, 

(z) Persons mentally infirm. 

(3) Idiots. 

(4) Imbeciles. 

(5) Feeble-minded. 

(6) Moral imbeciles. 

(7) Epileptics. \ 

iq\ t 1 • * Who are also 

(8) Inebriates. \ J „ , r A . 

1 \ t\ j. j j -u tr- j \ mentally defective. 

(9) Deaf and dumb, or blind J J 

[Recommendation IV.] 

Note.— (1) corresponds to "lunatics" and " insane " as ordi- 
narily understood. (2) corresponds to the various forms of 
" dementia." (3), (4), (5), (6), (7), (8), (9), comprise the several 
forms, varieties, and degrees of " amentia " which have been 
described in this book, and of which definitions have already 
been given (see Chapter V., " Classification "). 

III. That the providing of the necessary educational and 
custodial care shall be in the hands of the local authorities 
(County Borough, and County Councils acting through a 
statutory (" Committee for the Care of the Mentally Defective "), 
who shall be under obligation to make directly or indirectly 
suitable and sufficient provision for the manual, industrial, and 
other training of all mentally defective children, as well as for 
the care and control by institutions, homes, or houses, or in 
observation or reception wards, or under family guardianship, 



Appendix III 375 

or in any other way of which the Board of Control shall approve, 
of all such other sufferers from mental defect within their district 
as come within the terms defined in Section II. 

These local " Committees for the Care of the Mentally 
Defective " would therefore take over the work of the Education 
Committees, the Asylum Visiting Committees, and the Poor Law 
Guardians, in so far as these are concerned with the mentally 
defective. 

[Pars. 532-534 of Report and Recommendations 
XXVIII-XXXIV., XLVL, LXXIV.] 

IV. With regard to feeble-minded (" mentally defective ") 
children, the Commissioners advocate a system of record and 
limited notification, but, believing that the Defective Children's 
Education Act of 1899 by itself " cannot meet the needs of the 
mentally defective," they recommend that the education and 
training of these should pass from the Board of Education to the 
" Board of Control," the local authority being empowered to 
contract with the educational authority for the supply of schools 
and classes or other suitable measures, but being responsible that 
suitable control and training is supplied. 

The Commissioners insist upon continuity of control as a 
fundamental principle, and justly urge that the childhood and 
schooling of mentally defective children cannot rightly be 
treated apart from their after-life, and that no age can be fixed 
in their case as separating school-time from supervision and after- 
care. 

[Par. 23 of Report and Recommendations 
LXXII.-LXXXVL] 

V. In order to bring certain classes not now certifiable 
(notably feeble-minded and moral imbeciles) under efficient care 
and control, the Commissioners recommend that the procedure 
under the Idiots Act be extended so that not only idiots and 
imbeciles whose parents or guardians desire to obtain for them 
admission to an idiot asylum may be admitted on a single medical 
certificate, but also that feeble-minded persons, moral imbeciles, 
and such inebriates, epileptics, and blind or deaf and dumb persons, 
as are mentally defective, and of any age, may be admitted to 
suitable institutions in the same way. 



376 Mental Deficiency- 

Further, that the Idiots Act and the Lunacy Acts be re- 
modelled and drafted in the form of a single statute, which 
should contain all regulations for procedure, certification, and 
the supervision of institutions, which it may be necessary to insert 
in an Act for the care and control of the mentally defective. 
[Par. 27 of Report and Recommendations 
LXVIII.-LXXL] 



INDEX 



Abnormal nerve signs, 1 1 1 

in mentally defective chil- 
dren, 130 
Abstract ideas, 107 
Achondroplasia and cretinism, 257 
Act, Defective and Epileptic Chil- 
dren (Education), 124, 372 

Employers' Liability, 358 

Idiots, 371 

Lunacy, 371 
Action, deliberate, 112 

impulsive, 112 

reflex, 112 

spreading, 130 

volitional, 112 
Adenoids in Mongolism, 187 
Adenoma sebaceum, 88 
^Esthetic sense, 293 
After-care, necessity for, 358 
Age at which training should begin, 

339 
of aments at death, 92 
of feeble-minded in work- 
houses, 282 
of parents as a cause of amen- 
tia, 24 
Agenesis corticalis, 70 
Agnes Halonen, the case of, 267 
Alcohol as a cause of amentia, 18, 37 
effect of, upon eggs, 19 
susceptibility of aments to, 300, 
313 
Alimentary system, anomalies of, 

89 
Allegations, unfounded, by aments, 

134, 3i6 
Allowance, Poor Law, to aments, 

284 
Amaurotic family idiocy, 249 
Amentia accompanied by poren- 
cephaly or hemiatrophy, 220, 
221 
acquired, 15, 71 



Amentia, brain cells in, 56 

causation of, 14 

clinical varieties of, 72 et seq. 

congenital, 1 5, 71 

cretinoid, 182, 253 

definition of, 2 

degrees of, 74 et seq. 

delayed primary, 47, 72 

developmental, 47, 72 

diagnosis of, 324 

due to asphyxia neonatorum, 
213 
birth injury, 212 
blindness, 265 
cerebral disease, 196 

lesions, 202 
deafness, 264, 275 
defective cerebral nutri- 
tion, 251 
isolation, 263 
malnutrition, 261 
sense deprivation, 263 
sunstroke, 216 
toxic lesions, 218 
trauma, 314 203, 214 
traumatic epilepsy, 214 

eclampsic, 201 

epileptic, 197 

forms of, 71 

hydrocephalic, 235 

hypertrophic, 229 

incidence of, 4 et seq. See also 
Incidence 

inflammatory, 202 

myxcedematous, 253 

pachydermic, 253 

paralytic, 211 

prevention of, 362 

primary, ^y, 56, 71, 173. See 
also Primary 

prognosis in, 327 

rachitic, 262 

sclerotic, 224 et seq. 



377 



378 



Index 



Amentia, secondary, 47, 64, 71, 194. 
See also Secondary 
" sporadic," 45 
syphilitic, 240 
toxic, 202 

varieties of, 73, 173, 194 
vascular, 202 
with hemiplegia, 212, 214 
moral deficiency, 293 
motor aphasia, 218 
paralysis, 166, 192, 204, 

211 
paraplegia, 215 
Aments and crime, 298 
and society, 281 
in cottages, 288 
in workhouses, 282, 289 
insane, 310 
location of, 12, 281 
needing provision, 286 
number of, in England and 
Wales, 7, 368 ; method of 
estimating, 366 
pauper, 282 
propagation by, 288 
receiving Poor Law relief, 282 
sane, 310 
sex of, 13 
Andriezen, Dr. L., 19 
Anomalies, anatomical, 65, 80, 82, 
129 
of labour, 27, 29, 46 
physiological, 82, 89, 130 
Aphasia, motor, in amentia, 218 
Appearance of mentally defective 
children, 129 
of primary aments, 148, 160, 

166, 171, 194 
of secondary aments, 194, 210 
Aristotle on temperaments, 109 
Arithmetic in idiots savants, 274 

teaching of, 351 
Arndt and Sklarek, 67 
Articulation in aments, 117 
Asexualization, 360 
Ashby, Dr. H., 120, 130 
Asphyxia neonatorum causing 

amentia, 28, 46, 203, 213 
Association, capacity for, in 
aments, 105 
law of, 348 
systems, 58, 62 

cultivation of, 348 
Asylums, feeble-minded in, 284, 367 
idiots and imbeciles in, 284, 367 
Atavism and microcephaly, 174 
Athetosis, 117, 192 
correction of, 346 



Athyroidea, 252 
Atrophic sclerosis, 226 
Attention, cultivation of, 347 

in aments, 103, 161, 167 

in mentally defective children, 
132 

spontaneous, 103 

voluntary, 104 
Audry, 66 
" Aztecs," the, 180 

Baer, Dr., 296 
Baillarger, 174 
line of, 58 
Barr, Dr. M. W., 272 
Beach, Dr. Fletcher, 21, 123, 176, 

229 
and Shuttleworth, Drs., 16, 18, 

20, 23, 27 
Becker, Helene, case of, 180 
" Bird man," case of, 180 
Birth lesions causing amentia, 27, 

203, 208, 212, 215 
premature, causing amentia, 

30, 46 
Births, number of, to a marriage, 39 
Bischoff, Professor, 180 
Blindness, congenital, causing amen- 
tia, 265 
Blood in cretins, 256 
Bolton, Dr. J. S., 38, 62, 198, 263, 

3ii 
Bourneville, Dr., 18, 19, 60, 90, 223, 

226 
Boyd, Dr. R., 51 

Brachycephaly in Mongolism, 185 
Brain, atrophy of, 70 

in sclerosis, 225 
bloodvessels of, 61 
cells of, in amentia, 56 
in dementia, 64 
imperfect development of, 

57 
irregular arrangement of, 

56 
numerical deficiency of, 56 
Brain cells, pigmentation of, 58 
cortex of, 58, 61 
development of normal, 5 1 
haemorrhage into, 69 
hemiatrophy of, 66, 220, 221, 

223 
hypertrophy of, 60, 229 
in amentia, 65 
in cretinism, 255 
in criminals, 296 
in dementia, 70 
in microcephaly, 176 



Index 



379 



Brain, in Mongolism, 184 
in sclerosis, 59, 234 
inflammation of, 69, 202 
malformations of, 66 
membranes of, 70 
morbid anatomy of, 65 
regions of, affected in amentia, 

62 
situation of changes in, 61 
size of, and intelligence, 176 
range of normal variation 
in, 176 
weight of normal, 176, 364 
in hemiatrophy, 220, 223 
in hypertrophic amentia, 

229 
in microcephaly, 176 
in Mongolism, 184 
in porencephaly, 220, 223 
Bridgman, Laura, case of, 266 
Broca, Professor, 52 
Brothers and sisters of aments, con- 
dition of, 38 
Brunet, Dr. D., 229 

Caldecott, Dr. C, 16, 92, 93, 96, 188, 

259, 273, 275 
Cappelletti, Dr., 323 
Cardiac lesions in Mongolism, 187 
Cardona, Dr. F., 180 
Care, inadequate, aments under, 

286, 368 
Caswell, Oliver, case of, 267 
Catarrhal affections in Mongolism, 

188 
Causation, factors of, acting after 
birth, 3 1 ; before birth, 
25 ; during birth, 27 
age of parents, 24 
alcoholism, 18, 37 
consanguinity, 22 
convulsions, 32, 196 
diseases of nervous sys- 
tem, 16, 37 
ecbolics, 26 

environmental, 16, 24, 47 
epilepsy, 16, 32, 197 
extrinsic, 16, 24, 47 
gross cerebral lesions, 5 5 
heredity, morbid, 15, 34 
intrinsic, 15, 16, 35 
illegitimacy, 26 
injuries, 27, 31 
in regard to local varia- 
tions of incidence, 48 
malnutrition, 33 
maternal impressions, 26 
plumbism, 22, 25 



Causation, factors of, premature 
birth, 30, 46 
primogeniture, 30 
rickets, 33, 262 
slum life, 48, 127 
sunstroke, 32, 216 
syphilis, 21 
toxic, 31 

tuberculosis, 20, 37 
of primary amentia, 37 
of secondary amentia, 47 
Cells of brain, development of, 52 
in amentia, 56 
in dementia, 64 
Cerebellum, atrophy of, 234 
in hydrocephalus, 235 
in Mongolism, 184 
lesions of, in amentia, 67 
Cerretti, the brothers, 180 
Character in the feeble-minded, 149 
Charitable institutions, aments in, 

12, 288 
Charts of family histories, 41-45 
Children born during insanity of 
mother, 27 
dull and backward, 141 
dull owing to disease, 144 
epileptic, 145 
feeble-minded, 123 
insane, 145 

mentally defective, 123 
of delayed mental develop- 
ment, 143 
Choking, liability of idiots to, 167 
Chorea in aments, 117, 191 F 
Choreiform movements, 212 * 
Circulation in Mongolism, 187 
Civil incapacity of aments, 309 
Classification of amentia, 71 

table of, 77 
Clinical varieties of primary amen- 
tia, 173 
of secondary amentia, 194 
Clothing of aments, 334 
Clouston, Dr. T. S., 86, 87 
Colour-blindness in aments, 84 

discrimination, cultivation of, 
.342 
Commission, Lunacy, 8 

of Legislature of Connecticut, 

16 
Prison, 299 

Royal, on care and control of 
feeble-minded (of 1904), 4, 
125, 147, 281, 288, 299, 368, 

373 
Royal, of Sardinia on cretins, 

253 



3 8o 



Index 



Commission, Scottish Lunacy, 290 
Committee, Anthropometric, 296 
Departmental, of Board of 
Education, 124 
Common sense, lack of, in aments, 

158 
Compensation of neurones in cere- 
bral lesions, 206 
Complications of primary amentia, 

190 
Consanguinity as a cause of amen- 
tia, 22 
Consecutive lesions of brain, 67 
Consonantal defects in aments, 

121 
Contemporaries of aments, 38 
Contractures in paralytic aments, 
211 
in sclerotic aments, 226 
Control, defect of, in aments, 115, 
133, 299 
influencing responsi- 
bility, 306, 307 
inadequate, 286, 287 
Convulsions (see also Epilepsy) as a 
cause of amentia, 32, 196, 201 
as a cause of death, 96 
in amaurotic family idiocy, 250 
in amentia due to cerebral dis- 
ease, 211 
in epileptic amentia, 199 
in hydrocephalus, 237 
in mentally defective children, 

138 
in microcephalics, 179 
in Mongolism, 189 
in primary amentia, 190, 191 
in sclerotic amentia, 225, 226, 

230, 233 
in syphilitic amentia, 243 
Jacksonian, 211 
predisposition to, 201 
acquired, 202 
Co-ordination, defects of, 115 

development of, 345 
Coprolalia, 121 
Corporal punishment, 355 
Corpus callosum in aments, 55, 67 
Cortex cerebri, 56, 62 

in sclerosis, 234 
Cottages, aments in, 288 
Country, employment of feeble- 
minded in, 283 
Craniectomy in amentia, 332 
Cranium, anomalies of, in aments, 
70, 84 
in criminals, 296 
artificial compression of, 29 



Cranium, in hydrocephalus, 235, 237 
and rickets, 237 

in Irypertrophic aments, 229 

in microcephalics, 177 

in Mongolism, 185 

mensuration of, 85 

oxycephalic, 177 

premature synostosis in micro- 
cephaly, 174 

"sugar-loaf," 177 
Cretinism, 251 

endemic, 251 

description of, 252 
incidence of, 252 

sporadic, 253 

causation of, 253 
description of, 255 
differential diagnosis in, 

257 
pathology of, 254 
prognosis, 331 
treatment and its result, 

2 5 8 
Cretinoid idiocy, 182 

iminal actions in feeble-minded 
persons, 157, 298 
aments, 298 

and insanity, 300, 314 
number of, 299 
responsibility of, 305 
types of, 299 
responsibility, 305 
Criminals, habitual, antecedents of, 

297 
mental characteristics of, 

297 
physical characteristics of, 
296 
potential, 295 
relation of, to aments, 295 
Crocker, Dr., 89 
Crothers, Dr., 18 
Crowley, Dr. R., 128 
Cruelty of feeble-minded children, 

134 
of idiots, 169 
Cunning of aments, 134, 301, 302 
Cunningham and Telford-Smith, 

Drs., 181 
Cure of mental deficiency, 127, 328 
Cutaneous sensation, 10 1 

system, anomalies of, 88 
Cuvier, brain of, 176 

Dahl, Dr. Ludwig, 17 
Dalton, Dr., 181 
Darenth asylum, 22, 28 
Darwin, Dr. G., 23 



Index 



381 



Deaf - mutism causing secondary 
amentia, 264; cases of, 264- 
267, 303, 304 
in primary amentia, 193 
Deafness, cause of, 81, 100 
causing amentia, 264 
Death, age at, in amentia, 92 
in Mongolism, 188 
causes of, in amentia, 94, 96 
Definition of amentia, 2 

of feeble-mindedness, 75 
of idiocy, 76 
of imbecility, 76 
of mentally defective child, 75 
of moral deficiency, 76 
of " normal " mind, 2 
Degeneracy, stigmata of, anatomi- 
cal, 80 
in aments, 78, 194 
in criminals, 296 
physiological, 89 
Degeneration of brain cells, 64 
Degrees of amentia, description of, 

74 
prognosis in, 331 
Delisle, Dr., 30 
Delivery, instrumental, as a cause 

of amentia, 29 
Delusional insanity, 316 
Delusions in aments, 300, 314 
Dementia, condition of brain in, 62 
distinguished from amentia, 

1. 3 
in epilepsy, 197, 317 
in insanity, 317, 319 et seq. 
in primary amentia, 317 
in syphilitic amentia, 242 
Dentition in aments, time of, 90, 

364 
in cretins, 255 
Deprivation, amentia due to, 263 
Destructiveness in idiots, 169 
Developmental anomalies in 
aments, 65, 80, 89, 194 
in criminals, 296 
data, normal, 364 
or delayed primary amentia, 47 
Development, delayed, 128 

in children, 129, 143 
imperfect, of nerve cells, 57 
of normal brain, 5 1 
Diagnosis of amentia, 324 
of cretinism, 257 
of feeble-mindedness, 158 

in children, 138 
of hydrocephalus, 237 
of hypertrophy and hydroceph- 
alus, 229 



Diagnosis of idiocy and imbecility, 
171 
of mentally defective children, 

138 
of syphilitic amentia, 243 
Dietary in amentia, 334 
Disposition in amentia, 109, 134, 
150, 162, 168 
due to cerebral lesions, 210 
hydrocephalus, 236 
hypertrophy, 230 
in cretins, 256 
Dobson, Dr. M. B., 235 
Donaldson, Dr. H. H., 266 
Down, Dr. J. Langdon, 19, 20, 21, 
23, 24, 47, 86, 87, 91, 181, 
185, 210, 274, 329 
Down, Dr. R. Langdon, 187, 188, 

271, 273 
Drawing, capacity for, in mentally 
defective children, 137 
in idiots savants, 272 
Drugs in amentia, 332 
Dugdale, Dr. R. L., 298 
Dull and backward children, 141 
Dullness, mental, due to disease, 

144 
Duncan, Dr. Matthews, 24 
Dunces compared with aments, 141 

Ear, anomalies of, in aments, 80 
in criminals, 81 
in insane, 81 
and hearing, 100 
disease of, 100 
Earlswood Asylum, particulars re- 
garding mortality in, 
92 et seq. 
the Genius of, 275 
Earnings of feeble-minded persons, 

284, 285 
Ecbolics as a cause of amentia, 26 
Echolalia, 122 
Eclampsia and epilepsy, 202 

as a cause of amentia, t>3, 202 
" Eclampsic " amentia, 201, 218 
Edinger, Professor, 236 
Educability of aments, 339 

of mentally defective children, 
132 
Education Act regarding defective 
and epileptic children, 124 
Board of, report of Depart- 
mental Committee, 124 
of aments, general principles, 

335 
home, 339 
industrial, 351 



3 82 



Index 



Education of aments, intellectual, 

347 

moral, 353 

objects of, 335 

religious, 353 

school, 341 

technical, 351 

value of, 358 
Ego, perversion of the, 310 
Eichler, Professor, 55 
Ellis, Dr. Havelock, 296, 297 
Emotion in feeble-minded persons, 

155 
in mentally defective children, 

133 
in primary aments, no, 168 
in secondary aments, 210 
Employment of feeble-minded per- 
151, 155, 358 
in country districts, 

283 
in workhouses, 283 
vagrants, 285 
Encephalitis causing amentia, 217 

pathology of, 68 
Enteric causing amentia, 203 
Enumeration of aments, 4 et seq., 

366 
Enuresis, treatment of, 334 
Environment and heredity, relative 
importance of, 34 
and mentally defective chil- 
dren, 127 
factors of, causing amentia, 24, 
47. See also Causation 
Epicanthus, 84 

Epilepsy, acquired predisposition 
to, 202. See also Convul- 
sions 
and eclampsia, 202 
as a cause of amentia, 16, 32, 

198 
as a cause of dementia, 197 
exciting factors of, 202 
in children, 145 
in feeble-minded persons, 191 
in gross cerebral lesions, 190 
in idiots, 167, 191 
in imbeciles, 160, 191 
in microcephalics, 179 
in primary amentia, 117, 190 
Jacksonian, 21 1 
predisposition to, 202 
psychic, 62, 354 
relations of, to amentia, 196, 

204 
traumatic, causing amentia, 
214 



Epilepsy, treatment of, 334 
" Epileptic " amentia, description 
of, 197 
illustrative cases of, 199 
prognosis in, 331 
Epileptic insanity, 318 
Erotic tendencies in aments, 180, 

290 
Esquirol, Dr., 75, 118 
Ethnic types of amentia, jt, 
Examination of mentally defective 

children, 139 
Excitement determining insanity, 

313 
in aments, 155, 162, 168, 300 
Exhaustion of mother as a cause of 

Mongolism, 183 
Expression in mentally defective 

children, 130 
Extent of lesions in secondary 

amentia, 207 
Extrinsic factors causing amentia, 

24. 47 
Eye, anomalies of, 84. See also 
Vision 
drill, 346 
Eyes in Mongolism, 187 

" Facile " aments, 290, 299 
Factors of causation in regard to 

local variations of incidence, 48 
Fagge, Dr. Hilton, 253 
Family history charts, 41-45 
Farr and Newsholme, Drs., 40 
Fatty tumours in cretinism, 256 
Fecundity of neuropaths, 39 
Feeble-minded adults, 147 
character of, 149 
description of, 148 
illustrative cases of, 151, 

156 
incapacity of, 154 
in charitable institutions, 

12 
in lunatic asylums, 12, 284 
in Poor Law institutions, 

12, 282 
number of, 9, 147 
of stable mental equili- 
brium, 150 
of unstable mental equili- 
brium, 155 
receiving parish relief, 

282, 283 
sex of, 148 
children, 123 

abnormal nerve signs in, 
130 



Index 



383 



Feeble-minded children and slum 
life, 127 
clinical varieties of, 137 
" cured," 127 
definition of, 75, 124 
description of, 128 
grades of, 134 
incidence of, 125, 126 
in special schools, 135, 372 
mental condition of, 131 
number in England and 

Wales, 125, 373 
physical condition of, 129 
scholastic acquirements 
compared with ordinary- 
children, 135 
sex of, 128 
social status of, 128 
stigmata of degeneracy in, 
129 
criminals, 298 
insane, 311 
persons, 147 
vagrants, 285 
Feeble-mindedness, definition of, 

75 

Fennell, Dr. C. H., 186 

Fen wick, Dr. Soltau, 259 

Fere, Dr., 19 

Fibres of cortex cerebri, 58, 63 

Fingers in Mongolism, 187 

Flechsig, Professor, 62 

Foetus, injuries to, 27 

Forceps, use of, as a cause of amen- 
tia, 29 

Fournier, Dr. E., 21, 241 

Fraser, Dr. Alec, 220 

" Freddy," the case of, 181 

Fright, as a cause of amentia, 26 
determining insanity, 313 

Freud, Dr. S., 55, 69, 204, 207 

Fundus oculi in amaurotic family 
idiocy, 250 

Gambetta, brain of, 1 76 
Games, use of, in training, 346 
Garrod, Dr. A. E., 187 
General paralysis in aments, 317, 
323 
in syphilitic amentia, 242, 

244 et seq. 
morbid heredity in, 241 
Generative organs, anomalies of, 

89, 90 
" Genetous " idiocy, 73 
Genius, the, of Earlswood Asylum, 

275 
Germ plasm, how influenced, 35, 36 



Gestation, importance of mother's 
condition during, 45, 183, 184 

Giacomini, Professor, 174 

Gill, Dr., 289 

Gliosis, 59. See also Sclerosis 

Goitre in endemic cretins, 252 
in sporadic cretins, 253 

" Goose man," the, 180 

Gowers, Sir W. R., 33, 38, 198 

Gradenigo, Dr., 80 

Grandoni, Antonia, 180 

Gray, Dr., 307 

Grenzer, Dr., 87 

Grimacing in aments, 114 
in Mongols, 188 

Grinning in aments, 114 

Gross lesions causing amentia, 55, 
202 

Habits and tricks, 114, 346 
Haemorrhage, cerebral, 61, 69 
Hair, growth of, in aments, 88 
in cretins, 255 
in microcephalics, 177 
Hallucinations in ame'nts, 314 
Hammarberg, Dr., 56 
Hands in Mongols, 187 
Hauser, Kaspar, the case of, 268 
Head-nodding, 114 
Hearing and attention, 104 
cultivation of, 344 
defects of, 81, 100, 264 
in amaurotic family idiocy, 

250 
in cretins, 252, 256 
in hydrocephalus, 236 
in idiots savants, 271 
Heart, anomalies of, in aments, 
89 
in Mongolism, 187 
Helin, Dr. Aug., 267 
Hemiatrophy of brain, 66, 220 
Hemiplegia and amentia, 212, 214 
Heredity, alcoholic, 18 

and environment, relative im- 
portance of, 34 
morbid, and consanguinity, 23 
importance of, as a cause 

of amentia, 34 
modus operandi in causa- 
tion of amentia, 35 
neuropathic, 16, 17, 20 
in criminals, 297 
in general paralysis, 241 
in sporadic cretinism, 253 
in syphilitic amentia, 241 
syphilitic, 21 
tuberculous, 20 



384 



Index 



Heubner, Dr. O., 227 
High-grade amentia, 75 
Hirsch, Dr., 244 
Histology of primary amentia, 56 

of secondary amentia, 64 
Hjorth, Dr. B., 183 
Holt, Dr. E., 69 
Home training of aments, 339 
Homes, voluntary, for feeble- 
minded, 12, 372 
Horsley, Sir Victor, ^^^ 

and Sturge, 19 
Howe, Dr., 18, 266, 274 
Huschke, Dr., 184 
Hutchison, Dr. R., 258, 259 
Huth, A., 23 

Hybernation of aments, 91 
Hydrocephalic amentia, description 
of, 235 
and cretinism, 257 
and hypertrophy, 229 
illustrative cases of, 238 
Hydrocephalus, acute, 236 
and hypertrophy, 229 
arrested, "236 
cause of, 68 
causing amentia, 235 
cure in, 236 
in microcephalics, 235 
in primary amentia, 192 
pathology of, 68 
Hypertrophic sclerosis, 229 
and cretinism, 257 
amentia due to, 229 
Hypertrophy of brain and hydro- 
cephalus, 229 
amentia due to, 229 
pathology of, 60 

Ideation in aments, 106, 149, 151, 

167 
Idiocy, absolute, complete or pro- 
found, 171 
amaurotic family, 249 
and crime, 298 
apathetic and excitable, 168 
by sense deprivation, 263 
definition of, 76 
description of, 166 
diagnosis of, 171 
differentiation from imbecility, 

165 
illustrative cases of, 169 
maniacal excitement in, 169 
mental and nervous character- 
istics of, 167 
partial or incomplete, 166 
physical characteristics of, 166 



Idiots, number of, in England and 
Wales, 9, 165 
receiving Poor Law relief, 284 
savants, 270 et seq. 
sex of, 166 
Illegitimacy as a cause of amentia, 

26 
Illegitimate children of aments, 288, 

291 
Ill-health of mother during preg- 
nancy, 25, 183, 184 
Imagination in aments, 106, 161, 
167 
in mentally defective children, 

.133 
Imbeciles and mentally defective 
children, 145 
insane, 318 
in schools, 284 
number of, in England and 

Wales, 9 
receiving Poor Law relief, 284 
sex of, 159 
Imbecility, 159 

and crime, 298 
definition of, 76 
description of, 159 
diagnosis of, 171 
differentiation from idiocy, 165 
illustrative cases of, 162 
mental and nervous character- 
istics of, 160 
physical characteristics of, 160 
Imitation in aments, 106, 161, 355 
Imperfect development of nerve 

cells, 57 
Improvement in amentia due to 
cerebral lesions, 210 
limitation of, 339 
Incapacity, civil, of aments, 309 

of feeble-minded persons, 154 
Incidence of amentia, 4 et seq. 

in urban and rural dis- 
tricts, 49, 50, 126 
relative to insanity, 1 1, 49 ; 
to sex, 13 
of insanity, 1 1 
of mentally defective children 

in schools, 126 
of the respective degrees of 
amentia, 9, 50 
Inco-ordination, 115 

correction of, 346 
Industrial training, 351 
Infantile cerebral degeneration, 249 
Inflammation of brain, 69 
Inflammatory amentia, 202. See 
also Vascular 



Index 



385 



Injuries. See Trauma 
Insanity, alternating, 316 
anatomical basis of, 62 
and amentia, 3, 310, 311, 314 
and crime, 300, 314 
and dementia, 3, 317 
and town life, 49 
antecedent, as a cause of 

amentia, 16 
delusional, 316 
epileptic, 318 
in children, 145 

incidence of, relative to amen- 
tia, 1 1 
in feeble-minded, 311 
in idiots and imbeciles, 318 
in mother, effect upon children, 

27 
predisposition to, in aments, 

300, 311 
recurrences in, 316 
Instability of feeble-minded per- 
sons, 155, 300, 312 
Institutions, aments in, 12, 282, 

284 
Instrumental delivery as a cause of 

amentia, 29 
Intellectual sense, 293 
Intelligence and size of brain, 176 

training of, 347 
Interest, arousal of, 337 

importance of, in training, 347 
Ireland, Dr. W. W., 19, 20, 72, 87, 

229, 236, 253, 290 
Irregular arrangement of nerve 

cells, 56 
Isolation, amentia due to, 263 et 

seq. 
Itard's wild boy, 10 1 

Jacksonian convulsions, 211 
Jaws, anomalies of, 88 
Jendrassik, 60 
Jews and amaurotic family idiocy, 

249 
" Joe," the case of, 181 
Johnson, Samuel, 29 
Joints in Mongolism, 187 
Judgment in aments, 107, 149, 161, 

167 
Juke family, the, 298 

Kaes, Professor, 53 

Kalmuc variety of amentia, 181 

Keen, Dr., 333 

Keller, Helen, case of, 267 

Kerlin, Dr., 18, 20, 23 

Kind. Dr., 18 



Kindergarten occupations in train- 
ing, 337, 346 

Kingdon and Russell, Drs., 249 

Kleptomania, 308 

Klob, Dr., 55 

Knowledge of wrong, and criminal 
responsibility, 306 

Koch, Dr. J. L. A., 16 

Kolk, Schroeder van der, 298 

Korosi, Dr., 24 

Kundrat, Professor, 66, 221 

Labour, abnormalities of, as a cause 

of amentia, 27, 29, 46 
"Lalling," 120 

Lamination, cortical, in amentia, 
58, 61, 63 
in sclerosis, 234 
normal, 52 
Lankester, Dr., 26 
Lannelongue, Dr., 333 
La Page, Dr., 84, 86, 120, 129 
Law of England concerning aments, 

370 
Lead-poisoning causing amentia, 

22, 25 
Legal responsibility of aments, 305 
Lesions, cerebral, and amentia, 202- 
207 
age at occurrence, 205 
initial symptoms of, 

208, 209 
nature of, 207 
paralysis in, 208, 209 
prognosis in, 209, 330 
situation and extent 
of, 207 
consecutive, of encephalon, 67 
of motor cortex, effect of, 207 
Lewis, Dr. Bevan, 57, 61 
Lips, anomalies of, 84 
Little, Dr., 29 
Location of aments, 12, 281, 286 

needing provision, 287 
Lock wards, aments in, 289 
Logical sense in aments, 293 
Lombroso, Professor, 179, 180, 296 
Looft, Dr. Karl, 18 
Low-grade amentia, 76 
Lucon, Dr., 19 
i Lunatics, potential, 157. See also 
Insanity 

Malar flush in Mongolism, 187 
Malnutrition as a cause of amentia, 

33. 261 
Mania in aments, 314, 318 et seq. 
Marie, Dr., 60 

25 



3 86 



Index 



Marriage of aments, 288, 360 

restriction of, 360 
Marro, Dr., 298 
Masturbation in aments, 162 
Maternal impressions, 26 
Maternity wards, aments in, 289 
Maudsley, Dr. H., 274, 297 
McDowall, Dr. T. W., 177 
Measles as a cause of amentia, 203 
Meat diet, 334 
Medium-grade amentia, 76 
Melancholia in aments, 314 
Melland, Dr., 283, 289 
Membranes of brain, condition of, 70 
Memory, cultivation of, 348 
in aments, 105, 161, 167 
in idiots savants, 272 
in mentally defective children, 
132 
Meningitis causing amentia, 219 
Meningo-encephalitis causing amen- 
tia, 218 
pathology of, 68 
Menstruation in aments, 90 
Mental characteristics of aments, 98, 
103 
deficiency, literal meaning of, 1 
development, arrested, 262, 268 
delayed, 262 
normal, 51, 251, 335 
instability in the feeble- 
minded, 155, 300 
stability in the feeble-minded, 
150 
Mentally defective children, 123. 

See also Feeble-minded children 
Mcrcier, Dr. C, 307, 309, 310 
Meystre, case of, 267 
Microcephalic amentia, 173 
and atavism, 174 
and cranial synostosis, 174 
brain in, 176 
causation of, 174 
definition of, 173 
description of, 177 
intelligence in, 178 
morbid heredity in, 175 
pathology of, 175 
prognosis in, 329 
Microgyria, 66 
Microkinesis, 1 1 1 
Mill, J. Stuart, 354 
Mimicry in microcephalics, 179 

in Mongols, 189 
Mind, disease of, 3 

normal, definition of, 2 

development of, 51, 251, 
335 



Mind, normal, range of, 1 
types of, 293 
relation of, to nerve cells, 54, 
62 
Mind, Gottfried, case of, 272 
Mingazzini, Professor, 181 
Modesty in aments, 290 
Mongolian amentia, 181 

amelioration of bodily 

signs in, 188 
and cretinism, 189 
and syphilis, 22, 182 
causation of, 182 
description of, 185 
mental and nervous char- 

acterstics of, 188 
pathology of, 184 
physical characteristics of, 

185 
prevalence of, 182 
prognosis in, 329 
semi-, 182 
Moon, Dr. R. O., 202 
Moral deficiency, 293 

and amentia, 295 
latent, 295 

and criminals, 295 
imbecility, j6, 354 
sense, no, 133, 168, 293 
training, 353 
Morel, Dr., 19 

Mortality after craniectomy, ^^^ 
Mortality of aments, 91-97 

of cretins, 257 
Motor aphasia with amentia, 218 
cortex, lesions of, 207 
functions in aments, in 
cultivation of, 338 
in idiots savants, 270 
Mott, Dr. F. W., 21, 221, 241 
Movements, automatic, 114, 169 
co-ordinated, 1 1 1 
deficient, 113 
deliberate, 112, 115 
development of, 345 
excessive, 113 
imitation, 11 6, 346 
impulsive, 112, 115 
inco-ordinated, 1 1 5 
instinctive, 112 
irregular, 114 

correction of, 346 
reflex, 112 
training of, 345 
transfer, 116, 346 
spontaneous, 1 1 1 
volitional, 112, 115 
Muller, Professor Max, 121 



Index 



387 



Mumbray, Miss N., 135, 344 
Murray, Dr. G. R., 258 
Muscle sense, 101 

cultivation of, 343 
Muscles, anomalies of, 88 

atrophy of, in amaurotic family 

idiocy, 250 
condition of, in " paralytic " 

aments, 2 1 1 
sensations from, 343 
weakness of, in cretins, 256 
in sclerosis, 226, 230 
Music, fondness for, in idiots 
savants, 274 
in Mongols, 189 
value of, in training, 344, 350 
Mutilations, transmission of, 35 
Myxoedema and cretinism, 254 

Napoleon, brain of, 176 
National Vigilance Society, 290 
Nerve cells, development of normal, 
52 
in amentia, 56, 61, 63 
in dementia, 63, 64 
in sclerosis, 61 
Nerve fibres in amentia, 58, 63 
in dementia, 63 
normal, 53, 63 
signs, abnormal, in, 130, 324 
Nervous characteristics of amentia, 

98 
Neurasthenia in children, 145 
Neuroblasts in amentia, 57, 64 

in normal brain, 52, 62 
Neuroglia, condition of, 59, 224 

contraction of, 225 
Neuropathic heredity. See Here- 
dity 
Newsholme and Farr, Drs., 40 
Nicholson, Dr., 297 
Nobiling-Jolly, 55 
Norman, Dr. Conolly, 220 
Nose, anomalies of, 84 
in Mongolism, 186 
Number of aments in England and 
Wales, 9, 368 
inadequately cared 

for, 287, 368 
method of estimating, 
366 
Numerical deficiency of nerve cells, 

56 
Nystagmus, 117 

Object-lessons, value of, in training, 

348 
Occupation of aments, 151, 283, 285 



Occupations suitable for aments, 

352 
Offences committed by aments, 300, 

301 
Operative treatment of amentia, 

333 
Optic atrophy in amaurotic family 
idiocy, 250 
in hydrocephalus, 236 
Organic sensations in aments, 102 
Osseous system, anomalies of, 84 
Otitis as a cause of amentia, 203 
Otorrhoea in aments, 100 
Outdoor relief, aments in receipt of, 

282-284, 286 
Oxycephalic skull, 177 

Pachydermic idiocy, 253 
Pain, appreciation of, 102, 169 
Palate, anomalies of, 86, 87 
causation of, 87 

cleft, 87 

saddle-shaped, 87 

V-shaped, 87 
Palpebral fissures in Mongols, 185 
Paralysis, general. See General 
paralysis 

in amentia, 166, 179, 192, 204, 

211, 237 

nature of, in " paralytic " 
aments, 211 
" Paralytic " aments, 211 
Paraplegia in aments, 2 1 5 
Parasyphilitic conditions, 241 
Parents' disparity in age as a cause 

of amentia, 24 
Parry, Dr., 289 
Parturition, anomalies of, 27 
Pathology of amentia, 54 et seq. 
Paul, Dr. C, 22 
Pauper aments, 281 et seq. 
Peacock, Dr., 52 
Pearce, Dr. F. H., 92, 96 
Pearse, Dr., 289 
Peruvians, ancient, 176 
Petersen, Dr., 86, 271 
Phthisis. See Tuberculosis 
Physical characteristics of amentia, 

78 et seq. 
Physiological anomalies of amentia, 

89 et seq. 
Pigmentation of nerve cells, 58, 64 
Pituitary gland, administration of, 

in Mongolism, 190 
Play, use of, in training, 2>37> 34^ 
Plumbism. See Lead 
Pneumonia " aspiration," 334 
as a cause of death, 96 
25—2 



3 88 



Index 



Polio-encephalitis of Strumpell as a 

cause of amentia, 203 
Poor-Law institutions, aments in, 

1 2, 282, 284 
Porencephaly, 66 

as a cause of amentia, 5 5 

double, 222 

in primary amentia. 192 

in secondary amentia, 220 

pseudo-, 67, 221 

symptoms of, 220 
Potential criminals, 295 

lunatics, 157 
Potentiality of cerebral develop- 
ment, 205 
Potts, Dr. W. A., 283, 289 
Powell, Dr. E., 128 
Pregnancy, abnormal condition of 

mother during, 25, 45 
Premature birth as a cause of 
amentia, 30, 46 

synostosis in microcephalics, 

174 
Pressure, sense of, 102 
Primary amentia, causation of, 37 
clinical varieties of, y^> 

173 
complications of, 190 
pathology of, 56 
Primogeniture, 30 
Pringle, Dr., 89 

Prisons, aments in, 12, 299, 300 
Progeny of aments, 289, 290 
of insane mothers, 27 
of neuropaths, 39 
Prognosis in amentia, 327-331 

due to cerebral lesions, 
209 
cretinism, 258 
epilepsy, 199 
sense deprivation, 331 
sclerosis, 225 
syphilis, 245 
Pronunciation, defects of, 102 
Propagation by aments, 288 
prevention of, 360 
Prostitutes, 289, 290, 292, 299 
Provision, number of aments in 
need of, in England and 
Wales, 287, 368 
nature of, required, 359 
Puberty, mental changes accom- 
panying, 149, 169 
retardation of, in aments, 90 
in cretins, 252, 256 
in syphilitic aments, 242 
Punishment, effect upon aments, 
109, 301, 355 



Pupils in special schools, 135, 372 

in syphilitic amentia, 242 
Purkinje's cells, 234 

Quatrefages, 19 

" Rabbit man," the, 180 

Rage, attacks of, in hypertrophic 
aments, 230 

" Raphael, Der Katzen-," 272 

Rational type of mind, 293 

Reading, teaching of, 350 

Reasoning in aments, 107, 149, 161, 
167 
cultivation of, 348 

Recommendations of Royal Com- 
mission on the Feeble-minded, 

Recurrences in insanity, 3 1 6 
Reflexes in paralytic aments, 2 1 1 
Regions of brain affected in amentia, 

62 
Registrar-General, 39, 40, 97 
Relations of amentia to insanity, 

311 
of epilepsy to amentia, 196 
Religious education, 353 
sense, 293 

in aments, no, 134 
Rennert, Dr., 25 
Respiratory system, anomalies of, 

89 
Responsibility, conditions of, 309 

of aments, 305 
Rewards, use of, in training, 355 
Rhinitis in amentia, 203 
Ribot, Dr., 348 
Rickets and cretinism, 257 
and hydrocephalus, 237 
as a cause of amentia, ^^> 2 & 2 
j Ross, Dr., 222 
j Rossi, Dr., 297 
• Rumination, 167 
i Russell and Kingdon, Drs., 249 

I 

! Sabatier, 19 
i Sachs, Dr., 69, 70, 249 
'■ Sailer, Dr. J., 60, 234 
! Sander, Dr., 176 
Sangford, 266 
Saulle, Legrand du, 27 
Savage, Dr. G. H., 198, 310 
! Scalp in hydrocephalics, 237 

in microcephalics, 177 
! Scarlet fever as a cause of amentia, 
203 
Scholastic acquirements of imbeciles, 
161 



Index 



389 



Scholastic acquirements of mentally 

defective children, 134 
Schools, imbeciles in, 284 

special, description of children 

attending, 135 
training, 341 
" Scissor -legs," 166 
Sclerosis, contraction in, 225, 234 
diffuse, 59 

haemorrhage in, 61, 234 
hypertrophic, nodular, or tube- 
rous, 60 
in amentia, 193, 224 
localized, 59 
origin of, 60 
pathology of, 59 
Sclerotic amentia, 224 
diffuse, 225 

atrophic form, 226 
hypertrophic form, 
229 
localized, tuberous, or 

nodular, 233 
prognosis in, 331 
Secondary amentia, causation of, 47 
clinical varieties of, 73, 194 
pathology of, 64 
prognosis in, 330 
Seguin, Dr. ^douard, 271, 274, 327, 

336 
Sensations, importance of, to men- 
tal development, 98, 263 
Sense deprivation, amentia due to, 

263 
Senses, four chief, in normal mind, 

293 
Sensory functions, abnormal de- 
velopment, in idiots 
savants, 271 
cultivation of, 338, 342 
in aments, 98, 131, 160, 

167 
in cretins, 256 
in mentally defective chil- 
dren, 131 
Sentiment in aments, no 
Sex of aments, 1 3 

of idiots savants, 270 
of mentally defective children, 
128 
Sexual instincts, 102, 167, 290, 

298 
Shuttleworth, Dr. G., 21, 91, 123, 
181, 189, 330, 350 
and Beach, Drs., 16, 18, 20, 23, 
27 
Siege of Paris, 27 
Sichard, Dr., 298 



Simple variety of amentia, 73, 173 
Situation of aments, 12, 281, 286, 
287 

of brain changes in primary 
amentia, 61 

of lesions in secondary amentia, 
207 
Skeleton, anomalies of, 88 
Skin, anomalies of, in aments, 88 

in cretins, 252, 256 

in Mongols, 187 
Skull in amentia, 70, 84. See also 

Cranium 
Sleep in aments, 1 13 
Slums, effect of, in causation of 

amentia, 48, 127 
Small-pox as a cause of amentia, 

203 
Smell in aments, 10 1, 271 

cultivation of, 344 
Smith, Dr. F. J., 248 
Society and the ament, 281 
Sollier, Dr., 75, 90 
Speech, consonantal defects, 121 

cultivation of, 349 

in aments, 117 

in cretins, 255 

in idiots, 168 

in idiots savants, 272 

in mentally defective children, 

131 
in savages, 120 
in syphilitic amentia, 242 
nervous mechanism of, 117 
retardation of, 90 
Spiegelberg, Dr., 30 
Spiller, Dr. W. G., 206 
Spinal cord in amentia, 67 

in microcephaly, 175 
. secondary sclerosis of, 234 
Spontaneity, in, 335 
deficient, 113 
development of, 337 
excessive, 114 
Stammerers, 349 
Stature of aments, 88, 194 
of cretins, 255 
of criminals, 296 
of mentally defective children, 

130 
of microcephalics, 178 
Stephen, Sir Fitzjames, 306, 309 
Sterility in cretins, 256 

in idiots, 167 
Sterilization of aments, 360 
Stigmata of degeneracy in crimi- 
nals, 296 
in insane, 312 



39° 



Index 



Stigmata of degeneracy in mentally 
defective children, 129 
in primary aments, 78, 80, 

82 
in secondary aments, 194 
Still-births in neuropaths, 39 
Striimpell, Professor, 60 
Stupor in aments, 315 
Stutterers, 349 
Sugar-loaf cranium, 177 
Suicide in aments, no, 314, 315 
Sunstroke as a cause of amentia 32, 

203, 216 
Suspicion in aments, 210, 300 
Sutherland, Dr. G. A., 22, 182, 185, 

187, 258 
Sutures, cranial, in microcephaly, 

174 
Synostosis, premature, in micro- 
cephaly, 174 
Syphilis as a cause of amentia, 21, 
241, 243 
Mongolism, 22, 182 
Syphilitic amentia, 240 

and general paralysis, 242 
description of, 242 
diagnosis of, 243 
treatment in, 244, 332 
toxaemia, 241 

Talbot, Dr. E., 81, 87, 89 
Talents, special, in aments, 270 
Talipes in paralytic aments, 2 1 1 
Taste, cultivation of, 344 

defects of, 10 1 
Tay, Mr. Waren, 249 
Taylor, Dr. F. R. P., 226, 228 
Teeth, anomalies of, 88 
Telford-Smith, Dr., 187 
Temperament of aments, 108 
Temperature, appreciation of, 102 
effect of, upon aments, 91 
in amentia due to cerebral 

disease, 209 
in cretins, 256 
Thirst in aments, 102, 167 
Thompson, Dr. J. Bruce, 296 
Thomson, Dr. John, 87, 115, 186, 

254, 255, 258 
Thymus gland, effect of, in Mongol- 
ism, 190 
Thyroid gland, administration of, 
in cretinism, 258 
in Mongolism, 190 
condition of, in cretinism, 
252, 253 
secretion, effect of, upon brain, 
254 



Thyroid secretion, temporary arrest 

of, 260 
Tongue, anomalies of, 84 
in cretins, 252, 255 
in Mongolism, 186 
sucking, 186 
Touch, sense of, 10 1 

cultivation of, 343 
in idiots savants, 271 
in paraplegia, 216 
painful, 344 
Toxaemia, syphilitic, 241 
Toxic amentia, 202 

conditions causing amentia, 32 
Tracey, Mr. Justice, 305 
! Tracheotomy, necessity for, in 

aments, 167 
! Training, age at which to begin, 339 
effect of, in amentia due to 
lesions, 206 
sense depriva- 
tion, 263 
general principles of, 335 
home, 339 
industrial, 351 
intelligence, 347 
moral, 353 
of movement, 344 
of senses, 342 
of speech, 349 
school, 341 
value of, 358 
Train-wrecking by aments, 303, 

304 

Trauma as a cause of amentia, 27, 
; 31, 203, 214 

Treatment, 332 

in cretinism, 258 
in epileptic amentia, 201 
in syphilitic amentia, 244 
medical, 332, 334 
surgical, 332, 334 

Trelat, Dr., 274 

Tremor in amentia, 192, 211 v 
in sclerosis, 225, 226, 228, 230 
in syphilitic amentia, 242 

Tricks and habits, 114 

correction of, 346 

Tuberculosis, antecedent, as a cause 
of amentia, 20, $y 
as a cause of death, 96 

Tuke, Sir J. Batty, 2 

Tuke, Dr. Hack, 123 

Turgenieff, brain of, 176 

Ultimate result of cerebral lesions, 

203 
Umbilical hernia in cretins, 256 



Index 



39 1 



Umbilication 
225, 234 



of sclerotic nodules, 



Unstable type of feeble-minded, 155 
Urinary organs, anomalies of, 89 
Uterine exhaustion as a cause of 
Mongolism, 183 

Vagrancy, 285 

Vanity in imbeciles, 162, 278 
Vaquez, Dr., 256 
Varieties, ethnic, 73 

of mental action, 109 

of mentally defective children, 

137 
of mind, 294 

of primary amentia, 7$, 173 
of secondary amentia, j^, 194 
Vascular, toxic, or inflammatory 
amentia, 202 
causes of, 203 
illustrative cases of, 

212 et seq. 
initial symptoms of, 

208, 209 
mental condition in, 

210 
physical condition in, 

208 
prospects of improve- 
ment in, 210 
Vessels of brain, 61, 65, 203 
Vision, cultivation of, 342 

defects of, and cortical de- 
velopment, 263 
in amaurotic family idiocy, 250 
in amentia, 100 
in hydrocephalus, 236 
in idiots savants, 271 
in Mongolism, 187 
in syphilitic amentia, 242 



Vitality of aments, 91 
Vocabulary of normal child, 1 18 
Vogt, Professor C, 174 
Voisin, Dr. Felix, 176 

Dr. Jules, 18, 27,, 90, 271 

Walking, age at, in aments, 90, 255 
Warner, Dr. Francis, in, 116, 123, 

140, 344, 346 
Watson, Dr. G., 243 
Weight of brain in aments, 176, 184, 
220, 223, 229 
of criminals, 296 
of mentally defective chil- 
dren, 130 
normal, 176, 364 
Weismann, Professor, 35 
Wey, Dr. H., 296 
Whooping-cough as a cause of 

amentia, 203 
Wilbur, Dr., 179 

Will in aments, no, 161, 168, 306 
Wilmarth, Dr., 59, 184 
Wilson, Dr. G., 296 
Winslow, Dr. Forbes, 273 
Witnesses, aments as, 309 
Wizel, Dr., 274 
Work, capacity of aments for, 136, 

149, 151, 156, 161, 189, 283 
Workhouses, feeble-minded in, 282 
idiots and imbeciles in, 284, 

288 
maternity wards, aments in, 
289 
Works of the Genius of Earlswood 

Asylum, 276 
Writing, teaching of, 350 
Wyllie, Dr., 120 

Ziegler, Professor, 55, 66 



THE END 



Bailliere, Tindall &■= Cox, 8, Henrietta Street, Covent Garden 



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